Accessibility and utilization of maternal health care in urban India

Transcription

1 Accessibility and utilization of maternal health care in urban India A demand side perspective Utrecht University Faculty of Geosciences International Development Studies Master-Thesis, August 2012 A.A.A. Bennink Supervisor: Dr. Paul van Lindert

2 Acknowledgements This research project would not have been possible without the support of many people. I would like to take this opportunity to express my gratitude to the people who have been instrumental in the successful completion of this thesis. Firstly I would like to thank Dr. Paul van Lindert, my supervisor from Utrecht University, who made it possible to conduct my research at the host organization SAHAYOG. I am very grateful for his interest in my study and the time he has invested in providing me with helpful comments on the first draft of this thesis. Secondly, I would like to thank Ms. Jashodhara Dasgupta and Ms. Y. K. Sandhya for offering me an internship place at SAHAYOG and all the employees at this organization that have contributed to this study by translating my research materials and providing me with information that was of great value. In particular my thanks goes out to Ms. Palasri R. Das who welcomed me to Lucknow and the organization and who spared no effort in helping me with her excellent organizational skills. I would also like to thank her for introducing me to the partner organization Humsafar, which I am thankful to for making it possible to work with their employee Mrs. Sudha Singh. I would like to thank Ms. Singh for welcoming me in her house, for motivating the women of her community to participate in this study and the time she has invested in interviewing these women. Without her assistance this research would not have taken place. The quality of the data collection was greatly enhanced by the gracious assistance of Ms. Sneha Gupta and Ms. Prarthana Ramdas which I would like to thank for the time that they have invested in this study and the dedication they have showed while interviewing the women. Last but not least my gratitude goes out to the research participants. I would like to thank the women from Kashyap Nagar for their precious time which they have invested in this research and for their trust and honesty. This research is dedicated to these women as they were willing to share their personal stories with me and made it possible to write this thesis. 2

3 Executive summary Introduction Maternal health can be defined as the health of women during pregnancy, childbirth and the postpartum period (WHO, 2012c). Of all the maternal deaths in the world, 99% occurs in developing countries. The highest maternal mortality ratios can be witnessed in India where approximately 20% of all maternal deaths take place (Richard et.al. 2002). The majority of these deaths occur due to preventable causes. Maternal health care consists out of postnatal care during the pregnancy, skilled assistance during labor and postnatal care after birth. Both antenatal and postnatal care consist out of multiple health checkups in order to safeguard the health of mother and child. Unfortunately, many women are excluded from the health care system that is present in their country. This problem is strongly prevalent amongst Indian women from low socioeconomic groups, resulting in low or incomplete uptake of maternal health care. The barriers that woman come across when wanting to access health care can be categorized under five dimensions namely, Availability, Accessibility, Affordability, Adequacy and Acceptability (Penchansky & Thomas, 1981). These dimensions consist out of barriers that can be seen as supply side barriers and demand side barriers. Supply side barriers refer to various service delivery inputs such as the availability and quality of human resources and the availability of health facilities supplies and equipment, (Obrist et. al, 2007, Standing, 2004). The demand side refers to the behavior and inputs of the recipients of health care such as the ability to finance transport and care and their knowledge on the need for maternal care. This baseline study aims to provide an insight to the accessibility and utilization of maternal health care in a North-Indian city. The main goal of this study was to collect data on the degree in which maternal health care is utilized in medical facilities, the barriers that women came across when accessing this type of care and how women s experiences with accessing and utilizing maternal health care can influence their expected future behavior. Methods In order to get a better understanding of the accessibility and utilization of maternal health care in urban areas, research has been conducted in Lucknow, the capital city of the Northern Indian state Uttar Pradesh. Fifty women from the urban slum Kashyap Nagar have participated in this study by sharing their experiences on accessing and utilizing maternal health care during their last pregnancy. The data collection focused on the demand side perspective e.g. that of the women from Kashyap Nagar and a mixed method approach was taken. Data from the women s perspective was collected by the use of questionnaires and interviews. In order to get a good understanding of the demand and supply side barriers women were asked to indicate to what degree these factors influenced the accessibility of maternal health care. Women were also asked about their motivations for using maternal health care, how the location where they received this care was selected, their experiences with utilizing maternal health care and if they expect to utilize this type of care again when pregnant again. In order to present the supply side perspective of this topic, additional interview questions were asked to doctors working in public and private medical facilities in Lucknow. Subsequently the data was analyzed with SPSS in order to prevent the main findings. Also, case studies have been developed in order to get present the context in which these findings can be interpreted. 3

4 Main findings and conclusion It can be concluded that the utilization ratios in Kashyap Nagar are higher than the state average and that the majority of the researched women from this community have good experiences with accessing and utilizing maternal health care services in public and private health facilities. The majority (94%) of the researched women have utilized one or more components of maternal health. Antenatal care is the maternal health care component that is most often utilized by the women as 88% indicated that they received this type of care. During the delivery most women also receive skilled assistance as 50% gave birth in a facility and 44 women received assistance from a skilled birth attendance. Postnatal care has a lower uptake as only 66% of the researched women received any postnatal care after their delivery. Of the researched women 66% received ANC in a facility and 50% gave birth in a medical facility. Of the 33 women that received PNC the majority (63.6%) utilized this care in a medical facility. The majority of the women utilized the care in a public facility. Only eight out of the 50 researched women utilized MHC from a private health care provider. The care was predominantly utilized in public health care facilities e.g. in government Hospitals, PHC s and BMC s. When looking at the completeness of the utilized care, it can be noticed that the vast majority of the women does not use the recommended MHC that is of key importance for the health of mother and child. The average utilization ratio for ANC consists out of two checkups during the pregnancy, one checkup less than the recommended three checkups. 17 women did not receive the recommended during the months that they were pregnant. The assistance women received while giving birth has been incomplete in certain cases. Also, the quality can be questioned as in 50% of the cases the women gave birth at home and some cases received insufficient care in health facilities. The PNC that was utilized often (42%) consisted out of one vaccination or drug such as a painkiller. Only 12 of the researched women (24%) indicated that they received more than one post-natal check-up. When accessing the health services some of the researched women did have to overcome difficult barriers that were mostly related to the affordability and the acceptability of the services. This therefore implies that the strongest barriers to the access of MHC that women from this community encountered are a mix of supply and demand side barriers. Most of the women were able to overcome these barriers but those that did not succeed in doing so subsequently did not utilize any MHC in a facility. The research findings have shown that the earlier experiences women have with accessing and utilizing MHC are the two most important factors when deciding whether or not to utilize MHC in the future. It can be expected that these overall experiences women have had will have a positive influence on the future utilization behavior as most women indicated that these experiences were predominantly positive and because they indicated that they expect to use MHC again. However, this promising conclusion needs a side note. The future utilization of in-facility MHC by the researched women is strongly dependent on certain factors that are not controlled by the women and that can potentially emerge as new barriers. Firstly, the knowledge on the importance of maternal health care has a strong influence on the utilization behavior of women. The majority of the women indicated that they used MHC because they believed it was important for their own health and that of their child. The vast majority of the women retrieved this information from the people around them, especially from their family. Also the decision to use maternal health care and the location where the care will be utilized is strongly dependable on the knowledge and the approval of social relations, especially of that of their husband. The lack of autonomy in deciding when and where to utilize MHC can have negative consequences. For instance, if the opinion of the people surrounding the women 4

5 changes with regard to the acceptability of MHC, for instance due to financial restraints, the expected future utilization behavior can be negatively influenced as new accessibility barriers may arise. Secondly, factors that play an important role in deciding where to utilize future MHC are the very same factors where the women were less satisfied with, such as the availability of human and medical resources, waiting times and the attitude of the doctors and nurses. As Lucknow is currently witnessing the overcrowding of the health sector it can be expected that women will come across more hurdles when accessing MHC in the future as overcrowding is often related to problems such as long waiting times and rude behavior of nurses. These changing circumstances can therefore have a negative influence on the overall use of MHC and the in-facility use, which subsequently can be reflected in the maternal health status of the researched women. Therefore, it can be stated that the findings of the present study look promising but might be threatened by possible future barriers that may arise from factors that are currently very influential on the MHC utilization behavior of the researched women. 5

6 Table of contents List of abbreviations 10 Prologue 11 Introduction 12 Chapter 1 Theoretical Framework Introduction The international approach to the improvement of maternal health General approaches to health The Human Rights Based Approach The gender approach to health Approaches to the improvement of accessibility of health care The supply side approach The demand side approach Barriers to the accessibility of health care The five dimensions of Accessibility Conclusion 24 Chapter 2 Contextual Framework Introduction Maternal health a worldwide challenge Maternal health and maternal mortality Maternal health care services National Context Geographical location Demographics Ethnicity, language, religion and caste Socio-economic development 31 6

7 2.3.5 Status of women The Indian health care system Maternal health in India The Indian health care system Accessibility and Utilization of maternal health care in India Regional Context Geographical location and demographics Maternal health in Uttar Pradesh Lucknow city, geographical location and demographics The health care system in Lucknow city Conclusion 44 Chapter 3 Methodology Introduction Research questions Research questions Conceptual model Research methods Research approach and methods The questionnaire Operationalization of concepts The host organization Selection of the research area and units Selection of the research area Description and selection of the research units Research team Ethics Main limitations and risks 53 7

8 3.5. Conclusion 54 Chapter 4 Research location and participants Introduction Research location Research units Household situation Maternal history Conclusion 58 Chapter 5 Accessibility and Utilization Introduction Utilization of maternal health care Utilization of maternal health care in general Utilization of antenatal care Utilization of delivery care Utilization of postnatal care Experiences with accessing Maternal Health Care Availability Accessibility Affordability Adequacy Acceptability Personal characteristics Barriers perceived by women that did not use any MHC in facilities Experiences with utilizing maternal health care Overall satisfaction Facility Interaction with the health personnel 74 8

9 Referral Use of private health care facilities Expected future use Factors of influence on the utilization maternal health care Factors of influence on the choice of maternal health care provider Conclusion 80 Chapter 6 Discussion Introduction The accessibility of maternal health care in a theoretical context The gender and Human Rights Based Approach to health The demand side approach to health Accessibility, the perceived barriers in a theoretical context 85 Chapter 7 Conclusion Introduction The accessibility and utilization of MHC by women from Kashyap Nagar To what extent do women from Kashyap Nagar utilize public and private MHC? What motivates women to utilize maternal health care? How do women select the location where the maternal health care will be utilized? Which barriers reduce the accessibility of MHC and how do women overcome these? What kind of experiences do women have with utilizing public and private MHC? What factors do women expect to influence their future health seeking behavior? Final conclusion 92 References 94 Appendix 100 9

10 List of abbreviations ANC ANM AWC AWW BPL CDPO HDI IMF JSY MDG MMR NHP NRHM NUHM OBC PNC PHC PPP SBA UN U.P. WB WHO Antenatal care Auxiliary Nurse Midwife Anganwadi Center Anganwadi worker Below Poverty Line Child Development Program Officer Human Development Index International Monetary Fund Janani Suraksha Yojana Millennium Development Goal Maternal Mortality National Health Policy National Rural Health Mission National Urban Health Mission Other Backward Castes Postnatal care Primary Health Center purchasing power parity Skilled Birth Attendant United Nations Uttar Pradesh World Bank World Health Organization 10

11 Prologue Women living in urban communities in India face various obstacles when accessing maternal health care. The following story presents the story of one of the researched women that came in contact with various accessibility barriers which she had to overcome in order to receive maternal health care. The following case study aims to give an insight to the type of experiences women can have with accessing and utilizing maternal health care and which various factors come to play when deciding to use maternal health during a possible future. When 21 year old Lakshmi was pregnant of her first child she planned on using maternal health care as she had learned from her friends and the community that it was important to use these services. She visited a hospital so that she could receive antenatal care during her pregnancy. However, the doctor that was appointed to her refused to provide medical care to her as he believed that her child was illegitimate. After her bad experience with accessing care she was reluctant to visit a hospital again. Especially after she has seen that hospitalized women that were about to deliver their child, were beaten by doctors and nurses. But when she faced complications during labor she was rushed to a health center by her family. During the delivery none of the doctors or nurses was available or willing to assist her. When the baby was seconds from being born a sweeper that was cleaning the room intervened and assisted her while giving birth. Immediately after the delivery she was forced to leave the medical facility. As her family wanted her to receive postnatal care her husband got nutrition powders from a community health worker to strengthen his wife. He also visited a hospital with her parents, sister in law and neighbor where he had to pay a bribe of INR.700 (US $ 12.68) to the health personnel so that his wife would receive an injection against the pain she was feeling. The family paid these costs and an additional X-ray from the INR that they received under a conditional cash transfer scheme called Janani Suraksha Yojana. Looking back on her experiences when accessing maternal health care, Lakshmi recognizes many supply side barriers. She feels that the quality of the treatment she received and the cleanness of the facility were insufficient. Also the availability of doctors, nurses and resources was insufficient and their attitude was disappointing as all the care givers and the registration officer asked for bribes before wanting to distribute the care. However, what was most upsetting to her was the disrespectful treatment by the doctors and nurses. She believes that the fear she developed for hospitals due to the way the personnel treat patients, proofed to be the biggest barrier. She overcame this barrier due to the necessity of medical treatment and only received the medical care because her family paid the bribes that the personnel requested. Due to these experiences Lakshmi does not know how easy it will be to use maternal health care during a possible future pregnancy. Despite of the bad experiences she has had she feels that she would still try to use these services again in the future. However, her earlier utilization experiences and the opinion of her natal family and in-law-s could influence this expected future use. When selecting the location where she will utilize this care, the opinion of her husband, the availability and attitude of doctors and nurses and the experiences that friends have had will be decisive factors. 11

12 Introduction Inequalities in health and economic development influence the realization of human potential worldwide. The most essential obstacle to realizing human potential that can be recognized is the exclusion from social systems (London, 2008). The Universal Declaration of Human Rights (1948) safeguards the right to health but unfortunately this right is not met as many countries, and especially in developing countries, many are excluded from health care systems. Therefore, it can be stated that when persons are excluded from health care systems the human right to health care is often violated (Cook, 1993). Those that are excluded from utilizing health care are often part of the vulnerable groups in a society. In many countries and especially in those where patriarchal structures are prevailing, women are often those that are marginalized. Therefore, health standards are often not met by women. The deprivation of women s health can especially be recognized in the access they have to reproductive health. This type of health addresses the reproductive processes, functions and system at all stages of life (WHO, 2012g). Protection of women's reproductive health has often not been a priority for governments and women face many barriers when wanting to utilize reproductive health. The low uptake of maternal health care, which falls under reproductive care, demonstrates the need for services that are more accessible for women, especially those that are part of low socioeconomic groups. Maternal health addresses all the care women receive during their pregnancy, while giving birth and in the weeks after birth (WHO, 2012a). Utilization of these services is of key importance as poor maternal health can cause women to suffer from chronic complications and in the worst case, cause them to lose their life. In the last years progress has been made in improving women s maternal health as the worldwide maternal mortality has dropped by almost 50% in the last decades. However many deaths and inequalities can still be witnessed as 99% of all maternal deaths occur in developing countries from preventable causes, stressing the importance of focusing on the access of maternal health care in these regions. The highest maternal mortality ratios can be witnessed in India where approximately 20% of all maternal deaths take place (Richard et.al. 2002). Although the utilization rates of maternal health care in India have been increasing over the past years, large disparities between states, regions and households can be noticed. Women have often a disadvantaged gender position which becomes even more detrimental when women are poor and fall outside the cast system. A strong correlation between their low socioeconomic status and a low maternal health can be noticed. Many of the maternal deaths can be retraced to insufficient use of maternal health care during and after the pregnancy. Reasons for the low uptake of these services can be retraced to many factors, ranging from worldwide trends and policy shifts to the circumstances in which women live. When researching the accessibility of health care different perspectives can be taken to this topic as maternal health is influenced by developments on the global, national, sub-national and district level. However, as utilization of maternal health care ultimately comes down to the community level in which women live, it is of key importance to pay attention to the perspective of the women themselves. Therefore, the present study will take a demand side perspective on the access that Indian women from low socioeconomic groups have to maternal health care. As urban utilization rates of maternal health care are often higher than those in rural areas a research bias for rural studies can be noticed. A deeper understanding on the accessibility of 12

13 maternal health care in urban areas has often been overlooked by scholars and the civil society. However, by researching the accessibility and utilization in urban areas valuable information can be gathered on the development of maternal health in India. Insight can be given on factors that these women do not perceive as access barriers so that one can learn which dimensions are of importance when wanting to increase the utilization of maternal health. Also, a deeper insight can be given on how sufficient the higher uptake is to the improvement of maternal health on the manner in how sustainable the current developments are. For all of the above mentioned reasons this thesis will focus on the accessibility and utilization of maternal health care in urban India. The focus of this study will be placed upon the utilization of maternal health care in medical facilities. Women in urban areas often have to cover shorter distances to these facilities and therefore are face less physical barriers when accessing this type of care in a facility. In addition, is the use of facilities stimulated by the Indian government via the use demand side financing as it is believed that medical facilities are better equipped in providing a higher quality of maternal health care. In order to gather information on the research theme fifty women from the North Indian city Lucknow were surveyed on the their utilization behavior, the accessibility barriers they perceive and in which manner this influences their expected future behavior. The selected women were all residents of a slum area and had a minimum of one child in the last four to twelve months. Via the use of surveys and in dept interviews information was gathered on the research topics. In order to get an understanding of the supply side perspective on the accessibility of maternal health doctors were asked questions as well. This thesis begins by outlining presenting a theoretical framework in which general approaches to the improvement of health as well as those to the improvement of the accessibility of health care. Attention will also be paid to findings of empirical studies on the dimensions that can have an influence the accessibility of health care. In the next chapter, the contextual framework, an overview is given on the thematic and regional context in which the present study has taken place. Attention will be paid to the diversity of India, the Northern state Uttar Pradesh and Lucknow city. Also the Indian health system and the uptake of maternal health care in the state in which the present study has taken place will be discussed. In the third chapter the methodology of the study will be presented in which, inter alia, the research questions, conceptual model and research methodology will be discussed. The fourth chapter aims to provide an understanding of location where the research and the socioeconomic background of the research participants. In the fifth chapter the research findings of the present study will be presented. Subsequently will these findings be discussed in the light of the existing literature in chapter six. In the final chapter the conclusions of this study will be presented. 13

14 Chapter 1 Theoretical Framework 1.1 Introduction In this chapter an overview will be given of approaches to improve health in general as well as those that focus on the accessibility of health care. After a short overview of the international commitment to the improvement of maternal health, two general theories to health will be discussed, the Human Rights Based Approach and the gender approach to health. Next, two approaches will be discussed that are central to the improvement of the accessibility of health care, the supply approach and the demand approach. Lastly, an overview of barriers will be presented that according to diverse empirical studies have an influence the accessibility of health care. 1.2 The international approach to the improvement of maternal health During the years that development aid has been given to countries in the South, diverse approaches have been used by Northern countries to address the complex problems that prevent women from having children in a safe manner. The approaches used before the 1970 s in developing countries were often based on Northern systems of medical care, concentrating on urban medical centers and the use of highly trained personnel and modern technology (Rosenfield & Main, 1985). As it became clear that contextual circumstances in the developing countries formed barriers that influenced the accessibility of these services and that the primary health-care programs were not adequately focused on maternal health, new strategies were opted. Subsequently, a shift can be noticed since the 1970 s to an approach where the needs and resources of the developing countries were taken into account when designing and implementing medical systems. Yet, it was not until the 1980 s that the problem of high maternal mortality rates became a focus point. With the Safe motherhood initiative the growing need for more emphasis on maternal health care was being addressed as it called for global initiatives to intensify policy intervention for maternal mortality (Hogan et all, 2010). The focus on maternal mortality became an important issue in international aid and health services research during this decade (Brouwere et all, 1998). In the following years the focus was placed on the theme reproductive health as international commitment continued to contribute to the reduction of maternal mortality. International conferences, such as the Cairo Programme of Action, were held, and the goal to reduce the maternal mortality rates was set (AbouZahr & Wardlaw 2001). The approach to improving maternal health changed as well as during the International Conference on Population and Development in 1994 the focus on maternal health transferred from a demographically driven approach to a human rights approach (Potter et. al. 2008). Currently, this approach receives a lot of emphasis in international health (Standing, 2004). However, it was not until the development of the Millennium Declaration the reduction of maternal mortality became not only a focus point to the international community but a high priority, strengthening the international commitment (Hogan et all, 2010). More information on the millennium development goals and the improvement of maternal health can be read in Box 1.1. Currently, positive trends in the improvement of maternal health due to the influence of the Millennium Declaration can be noticed. However, research shows that more progress is needed to achieve the goals set for the year

15 Box 1.1: The Millennium Development Goals and the improvement of maternal health. In 2000 the Millennium Development Goals (MDG s) were adopted by the international community. These goals aim to encourage development by improving social and economic conditions in the world's poorest countries. Under the United Nations International Development Goal 5 Improve Maternal Health, the reduction of maternal mortality was adopted by the International Monetary Fund (IMF), the World Bank (WB), Organisation for Economic Cooperation and Development (OECD), and was supported by 149 heads of state at the Millennium Summit in 2000 (AbouZahr & Wardlaw 2001). This Millennium Development Goal (MDG) for 2015 includes target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio and Target 5.B: Achieve, by 2015, universal access to reproductive health (UN, 2012). This development goal is strongly interlinked with other development goals namely, MDG1 Eradicate extreme poverty and hunger, MDG3 Promote gender equality and empower women, MDG4 Reduce child mortality rates and MDG6 Combat HIV/Aids, malaria and other diseases. Therefore the MDG s can be somewhat seen as a holistic approach to improving women s overall wellbeing. By decreasing the maternal mortality rate (MMR) the economic effects for poor people will be reduced as well as the gap between maternal deaths of women from high and low socio-economic groups (Filippi et all. 2006). As low education levels and low statuses of women are often seen amongst those groups that have high maternal mortality rates, working on women s empowerment is expected to have a positive influence on decreasing the MMR. Because intra-partum and early postpartum strategies will not only improve maternal survival but will also have a positive influence on the survival of young children, MDG 4 is also strongly interlinked with reducing maternal deaths. Lastly, improving maternal health will also help the treatment and will reduce the spread of infectious diseases as mothers and their baby will undergo medical check-ups that can address infections and possible transmissions of diseases. 1.3 General approaches to health To improve general health care for the poor diverse approaches have been used throughout time. This paragraph presents an overview of two approaches that are currently often used namely the Human Rights Based approach and the Gender approach to health. Both approaches are important for the present study as they are often used in maternal health policy development The Human Rights Based Approach Human rights refer to the intrinsic rights that belong to individuals and that are equal to all human beings (UNDP, 2003). According to the Universal Declaration of Human Rights these rights are the foundation of peace, justice and democracy. With the adoption of the UN Statement of Common Understanding on Human Rights-Based Approaches to Development Cooperation and Programming by the United Nations Development Group in 2003, a consistent and coherent definition on the Human Rights-Based Approach was formed for the United Nations (UN). (HRBA, 2012) The Human Rights Based Approach (HRBA) was developed to realize the rights that are mentioned in the international human rights treaties. Although different HRBA approaches are being maintained in different organizations there are common factors that all approaches share. Firstly, the same stakeholders are being identified. HRBA s address two types of stakeholders. The first group consists out of those that do not experience full rights, also known as the right holders. The second group, known as the duty bearer, consist out of those that should be responsible for fulfilling the rights of the first group (Bruno-van Vijfeijken, 2009). With this approach a discourse between citizen-based rights and consumer focused views can be discovered. The HRBA views health as an entitlement instead of a market 15

16 based sector. As the latter differentiates uses based on their purchasing power it is considered by the HRBA as less suitable form of right as they tend to exclude the poor (Standing, 2004). Secondly, a common foundation can be noticed as all HRBA s aim to enable active social mobilization by using the agency of vulnerable groups. In this approach individuals, groups and communities are not seen as passive beings, emphasizing the importance of agency in HRBA s. These vulnerable individuals, groups and communities are seen as active agents with capabilities. The approaches aim to give them a voice that will enable them to make decisions and change their conditions of vulnerability (Londen, 2008). As mentioned there are multiple approaches that fall under the umbrella of the HRBA (UNAIDS, 2004). This is also the case with HRBA s in the health sector. According to Londen (2004) four different approaches can be distinguished when human rights are being used to promote health equity. In the first approach the human rights based framework is being used to design activities that support accountability and hold the government accountable as a duty bearer. The second approach lays its focus on pro-active development of policies and programs. This approach aims to operationalize health objectives in such ways that they are consistent with human rights. Here the approach helps the government to see how they can realize their tasks. In the third approach human rights violations are being restored by for instance addressing health violations in a court. The last approach uses the human rights framework to mobilize the civil society to realize the right to health. In order to achieve this goal various strategies can be used including holding governments accountable, developing policies and programs or addressing right violations. Besides these approaches a trend can be noticed in the HRBA s in the health sector. Current HRBA s aim to link the local with the global as new right based approaches to health policy development aim to link local struggles of vulnerable groups with the global context (Londen, 2008) The gender approach to health According to UN Women (2012) gender refers to socially constructed attributes and opportunities that are associated with being male and female and that are learned through socialization processes. In many countries and societies, women and girls are treated as socially inferior as gender norms and values attribute unequal responsibilities and rights. These gender inequalities are defined by the WHO (2012a) as differences between men and women which systematically empower one group to the detriment of the other. The effect that these inequalities have on the allocation of resources to women is strongly associated with poor health and reduced wellbeing. Studies have shown that the gender based inequalities that women face have a direct effect on the accessibility and utilization of health care services (WHO, 2009). This is for instance the case as women in developing countries are often hampered in their freedom of movement or not allowed to see a male doctor. In addition, studies have shown that there is a gender bias in the management of diseases, resulting in women often not being able to utilize the care that they need. However, gender norms and values are context specific and therefore subject to change, making it possible to have a better influence on not only the health of women but also on the enhancement of productivity and the improvement of development outcomes for the generation to come. In the 1994 Platform for Action document the statement was made that women's right to the enjoyment of the highest possible standard of health must be secured throughout the life cycle in equality with men (Gijsbers et al. 1994). One strategy to reach this goal is to create gender awareness via the WHO s gender mainstreaming approach. This concept stands for creating responsibility, knowledge and awareness of gender among all health professionals 16

17 (WHO, 2012). The approach promotes the inclusion of gender components in project s such as, research, interventions and health system reforms, from the start instead of including it in a later stage in the project. In this approach it is vital that all health professionals must be aware of the role that gender plays so that all can address this issue when needed. This approach is a reaction to previous strategies where often gender departments were responsible for addressing gender related strategies within running programs hence, decreasing their strength. The 2012 World Development Report (WDR) indicates that reducing gender gaps in health has been successful where a single barrier, in household, marker or institutional level, has been identified. Yet, in contexts where multiple barriers can be identified progress has been slower. Therefore, the need to place gender approaches central in the health sector remain of key importance. 1.4 Approaches to the improvement of accessibility of health care When aiming to improve maternal health in developing countries complex problems come to play. Optimal accessibility of health care is vital when trying to reach this goal. Improving accessibility is concerned with assisting people to claim appropriate health care aiming to improve their health (Gulliford et. al. 2002). Accessibility can be defined as the timely use of service according to need (Jacobs, 2011, p. 2). To achieve optimal accessibility the WHO paradigm Primary Health Care (PHC) was introduced to reduce inequities in health by enabling universal access to health care (Jacobs, 2011). As it often takes time before new health initiatives reach the poorest, targeting strategies are preferred when working in developing countries. The two targeting options for increasing the accessibility of health services are, building the capacity of the provider (the supply side strategy) or to reduce access and utilization barriers (the demand side strategy). Both strategies and affiliated approachess will be discussed in the next sections The supply side approach Within the health sector, a difference has always been made between demand and supply side mechanisms. Studies used to mainly focus on either the supply side of health systems or on health policy interventions that often aimed to reduce supply barriers (Ensor & Cooper, 2004). The supply side refers to various service delivery inputs such as the availability and quality of human resources, availability of health facilities, availability of supplies and equipment, protocols of diagnose, treatment availability and the environment of health facilities (Obrist et. al, 2007, Standing, 2004). The supply side barriers that arise for women of low socio-economic groups are rooted in problems related to inadequate supplies and unmotivated or unskilled health workers (Ekirapa-Kiracho et al. 2011). Supply side approaches often allocate resources to suppliers so that they can provide services based on the cost of inputs or train the health personnel in these facilities. The health seeking process of patients has been frequently left out and interventions that addressed patients were often limited to information, education, and communication campaigns. Supply side strategies focus on the state as service deliverer as it has the responsibility to ensure health care to its citizens (Berry et al, 2004). The state is appointed the role to finance, provide, regulate and monitor the delivery of health services so that the services are accessible for all. The role of the state as service deliverer is also supported by the 2004 WDR that states that the state must guarantee the provision of pro-poor services. Here a possible framework is proposed in which the relationships of accountability between the policy maker, the provider and the citizen are being examined. This approach is however criticized for being too narrowly 17

18 focused on the role that accountability has in improving the responsiveness of frontline providers (Berry et al, 2004). The report also addresses a challenge for the supply side approaches as states in developing countries are often unable or unwilling to commit to its responsibility. Problems like weak relationships between the policy maker, the provider and the citizens and weak state mechanisms are often to be found problematic. Supply side that strategies focus on these challenges include strengthen of pro-poor policy making functions, the building of provider capacity and the reduction of the barriers that the poor face and the increase of their participation (Berry et al, 2004) The demand side approach The demand side refers to the behavior and inputs of the recipients of health care (Standing, 2004). As supply side health reforms only had a limited success, attention shifted from the factors that hinder service uptake to the factors that influence the ability to utilize health care. Research suggests that removing demand side barriers may be just as important as supply factors in developing inclusive service delivery and hence improve maternal health. The demand side approach also developed due to the economic and institutional crisis and transformations of national health sectors such as marketisation and diversity in providers, the collapse of some public sector services, and governance and regulatory failures. Demand side approaches focus on the health seeking process in order to get a deeper understanding how individuals in the context of social groups and communities seek access to health care and on changing and improving the responsiveness of the supply side. The Grossman model explains that demand is influenced by factors that decide whether a person recognizes an illness and its willingness and ability to look for appropriate health care (Ensor & Cooper, 2004). The quality of the health care in this model is determined by the person as well as the community. The community can influence a person s preferences through cultural, religious and other social factors. The price of the medical care and the availability of resources are also taken into account in this model. Figure 1.1 gives an overview of some of the differences between the barriers that are being ascribed to the demand and supply side. In the following sub chapter a more elaborate overview of these factors will be presented. Figure 1.1: Barriers supply and demand side. Source: Ensor & Cooper, 2004 It is argued that one can try to improve health service delivery by either changing or assisting the health seeking behavior or, by addressing the change that is needed in the supply side. This has led to two views on what empowerment should be based on; an approach based human rights and social justice ideologies and an approach that is based on a consumer voice and choice ideology. These ideological differences have let to the development of six main approaches within the demand side approach. 18

19 According to Standing (2004) these approaches can be divided in the following groups: Behavioral change Rights-based approaches Improving accountability through the demand side Participatory approaches Multisectoral/multiple stakeholder approaches Demand side financing Changing user behavior to improve health outcomes has been approach that has been used in diverse interventions. Well known is the Behavioral Model by Andersen from 1968 that was developed to understand why families use health services; to define and measure equitable access to health care and to assist in developing policies to promote equitable access (Andersen, 1995). The underlying thought of these approaches within the demand side approach is that factors influence the behavior of people when seeking medical help and that education influences people to make healthier lifestyle decisions. Also the believe that the behavior of the individual and his surroundings are vital for health improvements and that some health use improvements can only derive from changes in behavior (Standing 2004). Currently, the behavioral demand side approach focuses on the manner in which messages are communicated. Terms like 'information, education and communication', and 'behavior change and communication' are often used. In the Rights Based Approaches from the demand side perspective, the discourse of rights stemming from empowerment and struggle from the grass roots level is equally important as the macro level view on rights that view these in the perspective of constitutions or international law. Grass root demand side elements in this approach in the health sector include the women s health movement, rights advocacy that focus on access. In this approach health is presented as a social justice issue that claims equal consideration and treatment on the basis of need. Accountability is a topic that is currently very high on the development agenda. In the health sector, civil society and intermediate organizations have been ascribed the role to provide pressure on the poor governance by providing alternative accountability structures. The improvement of accountability through the demand side is according to the 2004 WDR possible through the strengthening 'client power'. An example of such an approach is for instance making the income of health service providers more dependent on the demand from poor clients. The concepts of 'voice' (demand) and 'responsiveness' (supply) are seen as a fit way to operationalize accountability in health service delivery. As people are to a certain degree responsible for their health and that of those around them, they can have a participating role in the improvement of health care. As greater participation is frequently linked to the improvement of accountability there is an important role for (future) health recipients. Although the level of involvement may vary in different types of strategies, individuals and communities can participate in the struggle to improve health systems by for instance being involved in priority and standard setting, the mobilization of resources and the monitoring of services and providers. Due to the wide context in which improvement of health care for the poor must be realized, the multisectoral/multiple stakeholder approach is used. The creation of institutional arrangements and the emergence of diverse partnerships between diverse stakeholders are 19

20 important components of this approach. Also in this approach the emphasis on governance and accountability are important issues. Demand side financing has been defined as 'A means of transferring purchasing power to specified groups for the purchase of defined goods or services' (UNDP, 2006, p.19). This approach is well known for the use of conditional cash transfers and voucher schemes to potentially increase the demand for health services by those that make part of low socio-economic groups in developing countries. Demand financing brings different strategies together as it aims to change the provider behavior by promoting competition and choice and links demand to supply by targeting certain resources to disadvantaged groups. In addition it attempts to change demand side behavior by improve the tendency to utilize social sector goods by allocated transfers (Standing 2004). 1.5 Barriers to the accessibility of health care As mentioned in the previous subchapter, there are diverse barriers that stand between the need to use health care and the actual utilization of this service. In this paragraph an overview of supply as well as demand side barriers will be presented that according to diverse empirical studies have an influence the accessibility of health care and that are of importance in the light of the present study The five dimensions of Accessibility Accessibility can be of two main types; physical and socio-economic (Joseph & Phillips, 1984,). Socio-economic access itself is influenced by several variables that influence the utilization of a service. The socio-economic variables of influence are often; age, sex, mobility, income, knowledge and education level, social status and gender. Factors that influence the access to health care often translated into utilization rates. The degree of utilization of health services can be used to reveal the accessibility of a service, as the presence of a service does not guarantee the use. The level of use in relation to the need, can be used to measure the degree of accessibility. In this approach access can be considered in terms of whether or not those who need care can obtain it. When researching these barriers a framework can be used that selects five dimensions that encompass most of the barriers that patients come across namely; Availability, Accessibility, Affordability, Adequacy and Acceptability (Penchansky & Thomas, 1981). In this approach access can be seen as the degree of "fit" between the patients and the system. Table 1.1 presents the definitions of these concepts according to Obrist et. al (2007). Table 1.1: Five accessibility dimensions. Source: Obrist et. al Dimension Availability Accessibility Affordability Adequacy Acceptability Definition The existing health services and goods meet clients needs. The location of supply is in line with the location of clients. The prices of services fit the clients income and ability to pay. The organization of health care meets the clients expectations. The characteristics of providers match with those of the clients. 20

21 All five dimensions encompass multiple factors that have the potential to act as accessibility barriers. The dimension Availability addresses the type and number of existing services in relation to the number of patients and their type of need, in this case the need for maternal health care. It also encompasses the supply of health personnel and the availability of medical supplies and the degree that the offered products and services correspond with the needs of the patients (Penchansky & Thomas, 1981). Studies have shown that the availability of resources a sufficient amount of human resources, resources such as beds, medicines and donated blood and referral mechanisms are often insufficient (Hulton et. al. 2007). Accessibility addresses the relationship between the location of the care distributers and the location of the clients. Topics like transportation options and the travel time for patients also fall under this dimension. Studies have shown that the distance that women have to cover in order to reach health services can act as strong accessibility barriers (Ekirapa-Kiracho et. al, 2011, Obrist et. al, 2007) Affordability refers to the ability of patients to pay for the utilized health services, including the indirect additional costs (Bloom, 2001, Jacobs et. al, 2011). Included in these additional costs should be the transport costs and the time that utilizing care takes. Several studies have shown that the location and transport costs often seem to impact utilization negatively as these costs often make up for 25% of the total utilization costs (Ensor & Cooper 2004). Studies in several countries such as Vietnam and Ghana have shown that this negative relation also exists with respect to the time that patients have to spend on accessing and utilizing care. In addition informal costs, e.g. bribes, paid to health care staff or for commodities should also be taken into account as these costs have proofed to form barriers as well. Adequacy addresses the manner in which the clients expectations with regard to the facility are being met. Factors that fall under this dimension are for instance the opening hours and the maintenance status of the facility. The women s impressions of the state of the facility, for instance the beds, sheets and toilets influences the experiences women with utilizing care have (Hulton et. al. 2007). If these experiences are negative they can be perceived as barriers for further utilization behavior. Acceptability refers to the level in which the characteristics of health facilities take local and social values in count. This dimension addresses the relationship between the clients attitudes about personal and practice features of the medical providers and vice versa (Penchansky & Thomas, 1981). Whereas the first three accessibility dimensions of this framework refer to the provision of services by the health care system, the remaining two dimensions stand for the intrinsic quality of the health care from the point of view of the client (Gijsbers et al. 1994). Important factors for this dimension are for example patients receiving information on what the medical treatment encompasses and that questions are answered in an adequately and understandable manner. Studies have shown that women often do not receive any explanation to what was happening during their pregnancy and childbirth and that they often do not receive necessary health messages while being pregnant (Hulton et. al. 2007). The acceptability can also relate to the interpersonal skills of the health personnel (Jacobs et. al, 2011). About a quarter of women with low socioeconomic statuses that utilize maternal health care in a facility in a developing country have negative experiences with the health personnel, especially when receiving care from nurses or midwifes. These negative experiences range from being neglected and treated in an unequal manner to being disrespected by being verbally or physically abused. Research has for instance shown that in multiple countries women are shouted at or slapped during childbirth (Hulton et. al. 2007). 21

22 The acceptability of services also relates to the acceptance of health care utilization by the women s social relationships e.g. the community and household. Complex social, economic and cultural factors are often barriers to access and utilization of health care by women (Ojanuga & Gilbert, 1992). Cultural patterns and social factors can influence the accessibility of health care as for instance a study has shown that access to care for women in India is impeded due to the prevailing bias for boys exists with respect to the utilization of health care (Ensor & Cooper, 2004). Also the degree in which women are dependent on their husband s decision whether or not they can seek help and the influence that community s have on the decision making process can be seen as acceptability barriers (Stephenson & Tsui, 2002, Devadesan et. al. 2011, Ensor & Cooper, 2004). The above mentioned dimensions are likely to have a stronger impact on the accessibility of health care by poor and other vulnerable groups in comparison to those that have a higher socioeconomic as the costs of access, lack of information and cultural barriers often hinder the poor from benefiting from public spending (Ensor & Cooper, 2004). Factors related to the individual circumstances that have found to have an influence on the access to health and that are relevant for the present study can be brought down to the education level of a patient, the level of autonomy that women enjoy, the household situation of women and earlier experiences that clients have with utilizing health care. Research has shown that education has a positive correlation with good health (Ensor & Cooper 2004). Understanding the need of good health practices, knowledge about the characteristics of, and need for, medical treatment has a positive influence on especially the health status of women. A correlation can be seen between the education level of women and their maternal health care use. Autonomy has been defined as the capacity to manipulate one s personal environment through the control over resources and information in order to make decisions about one s own concerns or about close family members (Bloom et. al, 2001, p. 68). The level of autonomy that a woman has can be determined by looking at her control over finances, decision making power and freedom of movement. Research has shown that the relationship that a woman has with her natal family and mother in law often has an influence on her overall autonomy and access to health care (Sai and Raine, 2007, Bloom et. al, 2001). When women earn their own income and have a say in the spending of the household income this also increases her autonomy when wanting to seek health care as powerlessness often contributes to poor health outcomes and inaccessibility of health care services (Ojanuga and Gilbert, 1992). The accessibility of health care also interlinks with the previous experiences women have had with accessing and utilizing care. As earlier mentioned can supply side problems such as shortage in supply and unskilled staff can cause a client to have a negative experience when utilizing care and can an mixture of supply and demand side barriers have a negative influence on the accessibility of health care. The experiences that a client has had with previously utilized services can also act as a barrier for future use. When a client has had negative experiences in a health care facility it can result in the client not returning for further care. In addition, it can also influencing other client s health seeking behaviour and lead them to make the decision to not use the services as well (Cooper & Ensor, 2004). The quality of the clients experience is therefore essential in creating long term high utilization rates of reproductive health care services. Table 1.2. presents an overview of all the supply and demand side barriers that fall under the five A s, according to the existing literature. 22

23 Table 1.2: Supply and demand side barriers to the accessibility and utilization of health care Dimension Possible supply (s) and demand (d) Barriers Supporting Literature Availability Accessibility Affordability Adequacy Acceptability Personal characteristics Unqualified health workers, absent staff (s) Motivation of staff (s) Drugs and other supplies(s) Lack of opportunity (exclusion from services)(s) Late or no referral (s) Waiting time (s) Available transportation (s) Costs and prices of services (s) Household resources and willingness to pay (d) Transport costs (s) Lost in possible derived income (d) Bribes by health personnel (s) Availability of compensation schemes (s) State of the facility (s) Opening hours (s) Staff interpersonal skills, including trust, respect and dignity (s) Households expectations (d) Community and cultural preferences (d) Stigma (d) Knowing prices beforehand (s) Stories of other clients (d) Earlier experiences with utilization health care (d) Autonomy (d) Gender role in society (d) Socio-economic status (d) General education level (d) Aware of the importance of health care (d) Information on health care services/providers /compensations(d) Obrist et. al, 2007, Jacobs et. al, 2011, Hulton et. al. 2007, Paul et. al, 2011, Ekirapa-Kiracho et. al, 2011, Gijsbers van Wijk 1996 Obrist et. al, 2007, Ensor & Cooper, 2004, Jacobs et. al, 2011, Ekirapa-Kiracho et. al, 2011, Gijsbers van Wijk 1996 Obrist et. al, 2007, Ojanuga & Gilbert, 1992, Jacobs et al, 2011, Paul et al, 2011, Ekirapa-Kiracho et. al, 2011, Gijsbers van Wijk 1996 Obrist et. al, 2007, Hulton et. al. 2007, Jacobs et al, 2011, Gijsbers van Wijk 1996 Obrist et. al, 2007, Ensor & Cooper, 2004, Ojanuga & Gilbert, 1992, Stephenson and Tsui, 2002, Jacobs et al, 2011, Gijsbers van Wijk 1996 Obrist et. al, 2007, Ensor & Cooper, 2004, Ojanuga & Gilbert, 1992, Jacobs et al, 2011, Govindasamy & Ramesh, 1997 George, 2003, Ekirapa-Kiracho et. al, 2011, Joseph & Phillips, 1984, Bloom et, al, 2001, Stephenson and Tsui, 2002, Gijsbers van Wijk

24 1.6 Conclusion Access to health care is an entitlement that is unfortunately not a matter of course for many people, and particular women. Poor women tend to under-utilize health services and when wanting to reduce the number of women that die during pregnancy, childbirth or after delivery, complex problems come to play. Health care should be available, accessible, affordable, appropriate, and acceptable. In order to improve health outcomes in developing countries a holistic approach is of key importance and the use of only on strategy is not enough. Various barriers, ranging from the location where care is available to the level of autonomy a women has, can be distinguished that prevent women from accessing maternal health care. Therefore, it is of key importance that approaches address supply as well as demand side barriers as these barriers are not always mutually exclusive and tend to interact. In addition approaches should be gender sensitive. The following chapter will build on this first chapter by presenting the regional and thematic context of the present study. An overview will be given of the status of maternal health care in India and how contextual factors such as culture influences on maternal health care and government interventions influence the accessibility of maternal care

25 Chapter 2 Contextual Framework 2.1 Introduction This chapter aims to give an overview of the thematic and regional context in which the present study has taken place and consists out of three main sections in which the national, regional and local thematic context will be presents. The first paragraph of this chapter will provide information on maternal health and maternal mortality in general, and on the challenges that developing countries face when wanting to improve maternal health. In the second paragraph information will be given about India, the country in which the present study has taken place. Attention will be paid to geographical, demographic and cultural factors. Attention will also be paid on the Indian health care system. In the last paragraphs of this chapter the regional context will be discussed. In this section attention will be paid to the state Uttar Pradesh and its capital city Lucknow, where the present study has taken place. In these paragraphs more specified information will be given in order to give the reader a better understanding of the regional context in which the present study has taken place. This chapter will finish with a conclusion in which the following chapter will be introduced. 2.2 Maternal health a worldwide challenge Pregnancy and childbearing have brought risks for women throughout history. Maternal mortality is seen as a key indicator of women s health and status and shows differences between socio-economic classes. This sub chapter describes the international status of maternal health and mortality and explains what maternal health care encompasses according to international guidelines Maternal health and maternal mortality Maternal health can be defined as the health of women during pregnancy, childbirth and the postpartum period (WHO, 2012c). Maternal Mortality refers to the death of women during pregnancy, childbirth, or in the 42 days after delivery (AbouZahr & Wardlaw 2001). The World Health Organization (WHO) states that the major death causes for these maternal deaths are caused by hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor (WHO, 2012c). Annually women die in pregnancy and labor from preventable causes due to the lack of access to services (WHOb, 2012h). The majority of these deaths occur in the first 24 hours after delivery (Potter et. all. 2008). In addition to maternal mortality it is estimated that yearly 9.5 million women suffer from pregnancy related illnesses such as injuries and infections and disabilities. 1.4 Million Women suffer from the consequences of the life threatening complications that they endured (Filippi et all. 2006). Figure 2.1 gives an overview of countries and their maternal mortality ratios. Maternal health facts 99% of all maternal deaths occur in developing countries. Maternal mortality is higher amongst women living in rural areas and poorer communities. Skilled care before, during and after childbirth can save the lives of women and 25

26 Figure 2.1: Maternal mortality ratios for the year Source: WHO, 2009 The lack of access to skilled routine and emergency care plays a big role in the amount of women that die during or after their pregnancy. As maternal mortality clusters around delivery, the access to skilled attendants during and after birth and a timely referral for emergency care is vital (Filippi et al. 2006). As women in developing countries are increasingly seeking care during childbirth, it is also essential that the quality of the care provided is optimal. When looking at maternal mortality trends positive signs in the decrease of maternal mortality can be noticed. Between 1990 and 2010 the maternal mortality worldwide declined by 47% (WHO, 2012g). Some countries located in sub-saharan Africa have halved the number of maternal mortality and other regions have been even more successful as their mortality rates dropped even lower. Yet, not enough progress has been made as many disparities in maternal health statuses of women can be found. In developing countries a maternal mortality rate of 240 per births can be noticed versus 16 per in developed countries. Of the maternal deaths in 2010 almost all of these took place in low resource settings. In the latter only 46% of the women benefit from skilled care during childbirth and over a third of the pregnant women utilize the recommended four antenatal care check-ups (WHO, 2012b). The inequities in access to health services often highlight the gap between rich and poor. In developing countries the risk of a woman dying during or after pregnancy is very high, namely 1 in 31. In comparison with the western world a big contrast can be noticed as woman s life time risk in these countries is 1 in However, also large differences between the different developing countries and differences within the countries themselves can be notices as disparities between income groups and rural and urban areas often occur. As these complex differences and high maternal mortality rates continue to exist, maternal mortality remains a major challenge to health systems worldwide Maternal health care services Maternal health care encompasses various checkups. In order to get a general understanding of these procedures the three main components that maternal care consists of, antenatal care, delivery care and postnatal care, will be discussed in this paragraph. 26

27 Antenatal care (ANC), also known as pre-natal care, consists out of health checkups aiming to reduce health risks for the mother and child during and after the pregnancy. As many women in developing countries have nutritional deficiencies, it is estimated that almost half of all pregnant women worldwide have anemia, meaning that the health risks for mother and child are high. The WHO recommends a minimum of four ante-natal visits for pregnant women in order to receive a tetanus toxoid vaccination, screening and treatment for infections and for identification of warning signs during the pregnancy (WHO, 2012d). The importance of antenatal care lies in the possibility to assess risks as well as to detect and treat conditions, hence preventing potential lethal complications. In the years % of pregnant women in the world utilized the recommended minimum four times antenatal care. When looking at the utilization rates of antenatal care in developing countries a positive trend can be noticed. In developing countries the utilization of at least one antenatal checkup rose from 64% in 1990 to 81% in However, only 36% of these women received four of more times antenatal care during Research suggests that there has been little improvement over the last year. Furthermore, the quality of the care that has been provided is questionable. Care during childbirth ensures that obstetric emergencies are effectively managed. As mentioned in the first paragraph, most maternal deaths occur during or shortly after giving birth. These deaths could almost all be prevented if women would be assisted by a health care worker. However, recognition of complications by women and their surroundings and the availability of health workers with required skills, equipment and medicines are pre-conditions when wanting to prevent maternal deaths. Figure 2.2 gives an overview of births that have been attended by skilled health personnel in 7 countries, showing that women part of the poorest households still often give birth without the assistance of skilled health personnel. Figure 2.2: Births attended by skilled health personnel. Source: WHO, 2009 Postnatal care (PNC) is vital for detecting and treating infections and other conditions that mother or child can suffer right after the delivery. In addition, PNC can play a role in educating women and their families of detecting danger signs and care seeking behavior. The number of postnatal check-ups that should women should receive is under debate as there is no consensus on the final number that should be utilized. However, it is generally suggested that mother and child should make three or four postnatal visits. If the childbirth has taken place in a health facility it is strongly recommend that they are assessed within one hour after childbirth and before discharge (WHO, 2012e). Follow up contacts are recommended in the following time span: two to three days, six or seven days and six weeks after giving birth. Especially the post- 27

28 natal checkups in the first week after birth are vital as the majority of maternal and newborn deaths occur in this first week, especially on the first day (WHOd, 2012). 2.3 National Context This paragraph describes the geographical location of the present study, the demographics of India s population and the country s socioeconomic development. In addition it aims to give an understanding of aspects of the Indian culture that are relevant to the present study Geographical location The Republic of India is located in Southern Asia, bordering China, Nepal and Bhutan to the north-east, Burma and Bangladesh to the east and Pakistan to the west. The south of India is bounded by the Indian Ocean on the south, the Arabian Sea on the south-west, and the Bay of Bengal on the south-east. The Andaman and Nicobar Islands share their maritime borders with Burma, Thailand and Indonesia. This geographical location is shown in figure 2.3. Figure 2.3: Political map India Source: Oxford reference (2012) In India, three main geological regions can be distinguished namely the Indo-Gangetic Plain, the Himalayas and the Peninsula. The latter is known as South India and the first two regions are often referred to as North India. The country s lowest elevation is zero meters at the Indian Ocean. The highest point can be found in the Himalayas at Kanchenjunga. With 8,598 meters this is the third highest mountain in the world. Due to the large area that the country covers, diverse physiological regions such as highlands, plains, deserts, and river valleys are present. The exact size of India is subject to debate as some borders are contested. The UN lists the total area as 28

29 3,287,263 square kilometers and total land area as 2,973,190 square kilometers. Making India the seventh largest country in the world Demographics India consists out of 28 states and 7 union territories. India s population is the world world's second-most populous country. Due to its high growth rate, India has a fertility rate of 2.5, it is expected to be the world s most populous nation in 2025 (UNFPA, 2011). India had a population of 1.24 billion people in 2011, meaning that the country consists out of more than a sixth of the world population (UNFPA, 2011). Figure 2.4 presents the population spread across the country, highlighting the high density in the north. Figure 2.3: Population density in India Source: CIA World Factbook (2012) As in many developing countries, an urbanization trend can be noticed in India as many migrate from rural areas to the urban areas. As the urban population in the beginning of the 1950 s consisted out of 60 million people (17% of the population), last year s urban population consisted out of 31% of the total population. The annual urbanization rate from 2010 to 2015 is an estimated 2.4%. It is expected that by 2025, 42.5 percent of the population will be urban. The biggest city in India is the capital New Delhi which inhabits million people (CIA, 2012). Other major Indian cities are Mumbai ( million residents), Kolkata ( million) and Chennai (7.416 million). In these cities housing is a major problem, and has lead to very large slum populations. Problems like unemployment, underemployment and shortages of basic facilities such as clean drinking water, sewerage and electricity are no exceptions in these 29

30 communities. According to the 2001 Census the total slum population in urban India was 42.6 million, 15% of the total urban population (govt. India, 2008) Ethnicity, language, religion and caste India is not only known for its geographical and physical diversity but also for its cultural diversity. This high level of diversity is reflected in the various religions and languages that are present in this country. The following paragraph will give an overview of the ethnical, linguistic and religious context that are the foundation of this diversity. Special attention will be paid to the caste system and the implications for those that are being marginalized due to this system. Within the Indian society ethnic groups like the Indo-Aryan (72%), Dravidian (25%) and Mongaloid and other (3%) can be distinguished (World Factbook, 2012). Modern anthropologists classify Indians based on their ethnic origin as well as linguistic lineages in the following four types: Caucasoid, Mongoloid, Australoid and Negrito (IGVdb, 2005). The first two populations are mostly found in the northern and eastern parts of India, the Australoids are largely confined to central, western and southern India. The Negritos are only found in the Andaman Islands. The different groups also have different linguistic backgrounds as they belong to four major language families: Indo-European, Dravidian, Tibeto-Burman and Austro-Asiatic. The exception are the Andaman Islands where a linguistic isolated language developed known as Great Andamanese, that is not related to any known language. The number of languages that are spoken in India is under debate as various counting methods are used and many Indians are bilingual. According to the 2001 census there are 114 languages in India of which 22 are spoken by one million or more persons. In addition there are 1,600 dialects (Census, 2001). The most spoken language in India is the official language Hindi which is spoken by 41% of India s population. English is the subsidiary official language next to Hindi and is mostly used for national, political and commercial communication. Other languages that are spoken by many in India are Bengali (8.1%), Telugu (7.2%), Marathi (7%), Tamil (5.9%), Urdu (5%), Gujarati (4.5%), Kannada (3.7%), Malayalam (3.2%), Oriya (3.2%), Punjabi (2.8%), Assamese (1.3%), Maithili (1.2%) and other languages (5.9%). India counts various religious movements, with Hinduism being the most wide spread religion. 80.5% Of the Indian population is Hindu (World Factbook, 2012). Other religions that can be recognized are the Islam (13.4 %,) Christianity (2.3%) and Sikhism (1.9%). The northern states that border Pakistan and Bangladesh and the southern state Kerala and Lakshadweep islands have a higher percentage of Islam followers. In general, Christianity has flourished in the more southern and eastern states. The Indian society consists out of diverse groups based on ethnicity, language, religion, tribal group and caste. However, the Indian government does not recognize racial or ethnic groups within India but listed many of the tribal groups as Scheduled Castes and Tribes in The Constitution (Scheduled Tribes) Order (Census, 2001c). The Hindu caste system is nowadays illegal but is still widely practiced across India. The caste system consists out of four major castes called Varnas: Brahmins, Kshatriyas and Shudras. These Varnas are subdivided in hundreds of subcategories called jatis (Gifford & Zezulka-Mailloux, 2003). The Hindu caste system causes vertical hierarchism trough the Indian society under which scheduled casts have suffered for years. The scheduled casts call themselves Dalit, which means broken, and are deprived of many Human Rights under this system. The right of health is amongst these deprivations. The casteless Dalits, also referred to as untouchables or outcast, are on the bottom of the social latter and are often discriminated against by members of higher castes. Dalits are in charge of performing work that in India us seen as humiliating such as, the cleaning of drains, 30

31 gutters and toilets and the disposal of dead carcasses and bodies. Dalits make up for about 16% of the total Indian population and have due to the social stratification the lowest socio-economic status in India Socio-economic development The transition from a closed to an open market economy during the early 1990 s accelerated India s growth rate with 7% since India s integration to the global economy made India a newly industrialized country and a major global player as it has the fourth largest economy in purchasing power parity (PPP) terms (World Bank, 2012). Although more than half of India works in agriculture, services are the major source of economic growth as it accounts for more than India s output with only one third of country s the labor force. The educated English speaking Indians have become major exporters of information technology and software. Since 2011 India s economic growth has slowed down due to a high inflation and interest rates and the lacking progress of economic reforms. These reforms have largely suffered due to corruption scandals that had a negative impact on legislative work. Scientists have been skeptical about India s recovery due to the high level of poverty, and therefore high level of youth that has a weakened health and that are uneducated (UNFPA, 2011). Indian government officials have expressed confidence in the economy and the roll that the youth will play in the future. Yet, the World Bank (2012) expects the slowdown in GDP to carry on as it believes that the weakness in investment, tighter macroeconomic policies, slow growth in the core OECD countries and the possible next global recession will take its toll on India s economic development. Due to the increased development India was ranked place 134 of a total of 179 countries in the 2011 Human Development Index, indicating that it has a medium human development (HDR, 2011). Yet, this positive signal does not reflect on all of India s citizens. Although diverse indicators show progress and development, Dalits and especially women do not share in the success. Although India s middle class has been growing, the high poverty rates remain the biggest challenge in India s quest for development. Even though the poverty has been declining, the country still faces very high poverty levels that account for an estimated one third of the world s poor. According to the World Bank (2012) 68.7% of the Indian population lived in 2010 at US$ 2 a day (PPP) and 32.7% falls below the international poverty line of US$ 1.25 per day. Figure 2.4 presents a world map based on the percentage of the population that lives on less than 2 dollar a day in the years Figure 2.4: Percentage population living on less than US$ 2 a day. Source: file HDR 2007/

32 According to the Indian government did the percentage that lived below the poverty line declined by 7.3% from 37.2% in to 29.8% in (Govt. 2012b). It is also stated that rural poverty declined in 2010 by 8% to 33.8% and that urban poverty declined by 4.8% to a total of 20.9%. Yet, this development is unequal as the poverty rates among Dalit communities, schedule castes and schedule tribes are still higher than those among other groups (SIDA, 2001). Those that are the poorest in rural areas are those that are the lowest on the social latter namely the Scheduled Tribes (47.7%), Scheduled Castes (42.3%) and the Other Backward Castes (OBC) (31.9%). Of other classes 33.8% experiences poverty. In urban areas these marginalized groups also make part of the poorest as 34.1% Scheduled Castes experience the highest level of poverty followed by Scheduled Tribes (30.4%) and OBC s (24.3) against 20.9% for all higher classes. In rural areas nearly 50% of the agricultural laborers are below the poverty line in rural areas. In urban areas this type of poverty is high (47.1%) amongst casual laborers. A low education level (primary level and lower) of the head of the household is also translated in high poverty rates in both rural and urban areas. In order to improve the country s development, the government is investing in initiatives the will bring basis services such as education, health care, health insurance and infrastructure to the poor (World Bank, 2012) Status of women Women in India generally have a low status and a gender bias towards men influences their development in a negative way. In order to understand gender in India diverse factors such as increasing economic inequities, the feminization of poverty and the changing role of the Indian state within a liberal economy come to play (SIDA, 2001). In addition changing notions of caste, religion, and social traditions influence the role that gender has on the lives of women living in present India. The low position that women have in the current Indian society and the inequalities that they face hampers their development in various ways. The appointed gender role causes women to have for instance lower gross enrolment ratios and lower health statuses and, causes them to be less economically productive, politically involved and pressured to marry from a very young age. Women are particularly affected by religion as it often lays restrictions on their public and private roles. The development of women and their status is also undermined due to violence that is committed against women. Violent crimes, such as rape and sexual assault, and domestic violence, such as spousal abuse and dowry deaths, have an effect women s general and mental health, economic productivity, self-esteem and the welfare and nutrition of her children. India is ranked at 129 in the 2011 HDI with a value of 0.617, placing it at number 134 in the world rank out of a total of 187 countries with data (HDR, 2011). The gender bias towards men is also reflected in the Indian sex ratio. The sex ratio in India, which presents the proportion of women compared to the proportion of men in the country, was 940 females per 1000 males (Census, 2001). The 2011 Census indicated that the sex ratio for children was 914 females for 1000 males, indicating that the gap is increasing. The cultural view that male children are preferred over female children is an important reason that this ratio is unbalanced in favor of men (Patel, 2002). The under-five mortality rates and malnutrition are higher for girls than for boys, which is often explained by a bias towards sons in regard to early childhood care. In addition, India has witnessed a trend in female foeticide and sex selective abortion as the estimates of number of selective abortions of girls rose from 0-2 million in the 1980s, to million in the 1990s, to million in the last decade (Jha et. al, 2011). Low infant and adult sex ratios are widely seen to be indicators of the miserable situation of women in India (SIDA, 2001). Figure 2.5 gives an overview of the Indian sex ratio in 2001 indicating, that the states Punjab and Haryana show the largest male/female disparities. 32

33 The higher disparities in northern states can explained by the stronger gender bias that is often prevailing in Northern Aryan kinships. Figure 2.5: Indian sex ratio Source: SIDA, 2001 Studies have shown that there is no significant association between the caste of Indian women and the extent of female disadvantage in child survival. Many observers have attributed this contrast to the relatively egalitarian character of gender (Murthi et. al. 1995). However, there is a correlation between the sex ratio and maternal mortality rates. The explanation for this correlation is often brought back to cultural explanations, discrimination in nutrition and differential access to health care whilst the government health expenditure is low. In the Indian constitution gender equality is ensured as a fundamental right which also empowers the state to adopt measures of positive discrimination in favor of women by ways of legislation and policies (Patel, 2002). The development of various conventions on equal rights of women, policies, laws and acts such as the Pre-natal Diagnostic Tech Act in 1994 have been also been introduced to remove gender discrimination. Yet, persistent gender inequalities, violence against women, poverty and restricted access to resources for women show that achieving gender equality in India continues to be a major challenge. 2.4 The Indian health care system The following paragraph gives an overview of maternal health in India and presents the health care system of India. When discussing the health care system attention will be paid to the overall public health structure and the three stakeholders that can be recognized in the India health system namely the Indian Government, the Private sector and NGO s. Next, the accessibility and 33

34 Utilization of maternal health care will be discussed to provide an understanding of the maternal health care use in India Maternal health in India India has very high maternal mortality ratio in comparison to other countries as approximately 20% of all maternal deaths in the world take place in India (Richard et.al. 2002). Within the country a wide range of maternal mortality rates can be seen, with especially poor and marginalized women suffering from rates far higher than the national average. In the last 30 years a positive trend can be recognized as India s maternal mortality ratio substantially declined from 677 maternal deaths for every 100,000 live births in 1980 to 254 in 2008 (CRR, 2011). Over the MDG period a decline in the MMR can be witnessed of 4% (Hogan, 2010). The increase of skilled birth attendance has been a major contributor to this development. Yet, still more women die in childbirth in India today then European countries witnessed over a hundred years ago due to reasons that can easily be prevented. Table 2.1 presents the Indian MMR since Table 2.1. Indian MMR per 100,000 live births. Source: Hogan, 2010 Year MMR mean MMR minimum MMR maximum The Indian health care system In the Indian health sector diverse institutions are present, ranging from government services to private health care facilities and NGO s. In the following paragraph these three stakeholders will be discussed. The national expenditure on health by the Indian government shows a positive trend. The government has been criticized by different scholars with respect to its national expenditure as it percentage of GDP spend on health used to be 0.9%. The neglect of reproductive health can be seen as a major cause of the levels of avoidable maternal death (Cook, 1993). In the last decade the expenditure rose from 0,9 to 2% in 2010 and the State sector health spending increased from 5.5% to 7% of the budget in 2005 to 8% in 2010 (UN, 2012b). However, this positive trend did not occur in all states during these years as the public health expenditure also declined in poor states as Uttar Pradesh (SIDA, 2001). The structure of the Indian health care system can by divided in different levels; the national level, state level, district level and community level. The national level consists of the Union Ministry of Health and Family Welfare which has three departments: Health, Family Welfare and Indian System of Medicine and Homeopathy. Each state is headed by a Minister and has a Secretariat under the charge of Secretary/Commissioner (Health and Family Welfare). The organizational structure in the state mirrors the pattern of the central government. The director of Health Services is the head of the State Department of Health and Family Welfare. This structure can however differ amongst states but all have program officers that focus on one and more subjects. In various states, including in the state where the present study has taken place, there have been zonal, regional or divisional set-ups created between the State Directorate of Health Services and District Health Administration. Each of these regions covers 34

35 three to five districts and acts under authority delegated by the State Directorate of Health Services. The district level structure interlinks the state and the regional structure as well as peripheral level structures such as Public Health Centers (PHC s). The information that is received from the state is being adjusted and transmitted by to the periphery so that health services meet the local needs of the district. The Chief Medical and Health Officer have the overall control. On the community level Community Health Centers are available for every 80,000 to 120,000 persons to provide basic health services. In order to address the problems with respect to maternal health in India, the government also implemented various programs. In 1997 the Reproductive and Child Health program was launched (Stephenson, 2002). This program was based on the existing Safe Motherhood Program and linked maternal and child health with the strengthening of referral systems for obstetric care. The RCH was followed by the RCH-II program that besides immunization, antenatal care and skilled attendance during delivery also focused on reducing maternal mortality (Richard et. al., 2002). In the same year the National Rural Health Mission (NRHM) was launched by the government to strengthen health services in the rural areas. This program aims at improving the availability and accessibility of effective health care for especially people residing in rural areas (Govt. of India, 2012). Strategies of this program include improving access, community ownership, strengthening of public health systems, enhancing accountability and promoting decentralization. With the 2002 National Health Policy (NHP) the accessibility in service delivery was addressed. With the NHP the government aimed to evolve the policy structure in a manner that it would reduce inequalities and make public health services accessible for the poor achieving an acceptable standard of good health in India (UN, 2012b). By decentralizing the public health system and improving the infrastructure this strategy aimed to ensure a more equitable access to health services in the country. As the urban population in India has increased and is it is expected to continue this trend in the following years, the Indian government has recognized the need for attention for urban health (Govt. of India, 2010). Despite the closeness to health facilities, India s urban population has a restricted access due to the inadequacy of the urban health delivery system and demand side factors such as the socioeconomic status of the women. In order to effectively address the urban health care problems the National Urban Health Mission (NUHM) has been designed by the Indian Government. Within this intervention the inaccessibility of the health care facilities in urban areas will be addressed. With this intervention the following problems are being recognized; overcrowding of patients, ineffective in outreach and referral system, lack of standard and norms for urban health care delivery system, social exclusion, lack of information and assistance to access the modern health care facilities and lack of economic resources (Govt. of India, 2010). Figure 2.6 shows the structure of the urban healthcare system according to the NUHM. It gives an overview of the different levels in urban health care delivery and explains when services will be delivered by whom. 35

36 Figure 2.6: Urban Health care Delivery model. Source: Govt Unfortunately the NUHM has not been implemented in the city where the current study has taken place. Therefore, the structure that can be found in the region where the current study has taken place will be presented in the next section of this chapter. In addition to an adapted health care strategy and newly developed programs the India government also aims to make health care more accessible through demand side financing. This concept aims improve access to and utilization of health services, particularly among the poor. Diverse initiatives for urban as well as rural areas can be found. The Conditional cash transfer scheme (CCTS) Janani Suraksha Yojana (JSY) or Women s security scheme is the most widely implemented scheme that is fully sponsored by the government and that falls under the umbrella of the National Rural Health Mission (WHO, 2010). In textbox 2.1 more can be read about this initiative. Textbox 2.1: Janani Suraksha Yojana Via the Janani Suraksha Yojana cash is being transferred to assist poor pregnant women to give birth with the assistance of a skilled birth attendant. The JSY is the largest conditional cash transfer programme in the world in terms of the number of beneficiaries, and represents a major Indian health programme (Lim, Dandona et. al. 2010). Its main objective is to increase institutional deliveries amongst Below Poverty Line (BPL) women and thereby reduce overall maternal and neonatal mortality rates (HSO&P, 2008). According to JSY s guidelines, after delivery in a government or accredited private health facility, women receive 600 Indian rupees (US$13.3) in urban areas and 700 rupees ($15.6) in rural areas. In ten high-focus states, including Uttar Pradesh, that have a low in facility birth coverage, all women irrespective of socioeconomic status and parity are eligible for the cash benefit. The cash incentive is higher in these states than in the other states namely 1000 rupees ($22.2) in urban areas and 1400 rupees ($31.1) in rural areas. In the non-high focus states, women are only eligible for the cash benefit for their first two live births, if they have a government-issued belowthe-poverty-line card or if they are from a scheduled (low) caste or tribe. Like the national maternity benefit t scheme, JSY also provides a small amount of financial assistance of 500 rupees ($11) for the two first home births by women that live below the poverty line and that are 19 years or older. Health workers from high focus states that introduce the women receive payments of 200 rupees ($4,4) in urban areas and 600 rupees ($13,3) in rural areas per in-facility delivery that they assist in. 36

37 In addition, there are also CCTS s that address the private sector and that are non state led initiatives such as the Agra voucher and the Sambhav voucher scheme. These schemes are designed for women of reproductive age living below the poverty line. Via these schemes vouchers are handed out which can be used by the targeted women to receive free maternal health services. With this approach NGOs and health volunteers are involved in mobilizing beneficiaries, management and disbursement of vouchers (Gupta et al. 2010). The development of the private health sector can be traced back to the bias towards the inadequacy of Primary Health Centers (PHC s) and the Structural Adjustment Programs that were implemented in the 90 s in India. Within India a bias towards the urban area could and can be noticed in terms of availability of health care facilities as most of these are located in urban areas (SIDA, 2001). PHC s were established to cover the Indian population in all regions. However, due to a shortage of centers and poor health care a large private health sector has developed. Under the Structural Adjustment Programs health centers and services have been increasingly privatized. It is estimated that 84% of health expenditure is now private. A large share of this household health expenditure comes from the poor, spend on improper treatment, drugs for self-treatment or as a result of their unavailability in public facilities (Standing, 2004). The privatization of the health sector often leads to the diminishment of the degree in which patients need are met due to sector s focus on profit (Londen, 2008). Negative consequences of the privatization of the health industry with the respect to the level of accessibility for the poor is amongst others the introduction of user fees, the possible strengthening of the male bias towards health care due to rising health costs and higher drug costs. NGO s often, with government support, implement community based programs to promote community interaction and involvement and by educating and providing incentives to involve the community in health initiatives the NGO sector aims to improve the health status of those with a low socioeconomic status Accessibility and Utilization of maternal health care in India As mentioned earlier on in this chapter is the Indian health system is not fully accessible for all its population, especially for those that have a low socio economic status. The barriers that woman face correspond with the barriers that are being experienced in many developing countries and that can be brought back to the five dimensions; Availability, Accessibility, Affordability, Adequacy and Acceptability. The accessibility of maternal health care services suffers under the demand as well as supply side barriers that have been discussed in the theoretical framework. The influence that gender has on maternal health care utilization is still prevalent in India as women found in a disadvantage when it comes to health care utilization (SIDA, 2001). Specifically the lack of education is also seen as a major barrier as well to effective access to services in India. The utilization of maternal health care varies amongst the Indian population. Differences exist between states, regions within these states and households. The states with the highest development rates, urban areas and households with higher socioeconomic statuses, are those with the highest utilization rates. When taking the income level of households into account it can be seen that households with a low income in general seek less treatment. In general these households treat less than half of the illnesses that they suffer, subsequently spending a low percentage of their household income on health. High income households generally seek treatment 65% of the cases (SIDA, 2001). The utilization of Antenatal care (ANC) in India has slightly increased between 1998/1999 and 2005/2006 as almost 15% more pregnant women receive ANC as 37

38 approximately 76% of women the researched women received ANC. Of these women 74% did so from a skilled provider (WHO, 2012f). Figure 2.7 gives an overview of the percentage of women that received ANC. Figure 2.7: Percentage of antenatal care visits. Source: WHO, 2012f Of the births that took place between 2000 and 2005 approximately 39% occurred in health facilities. Figure 2.8 shows that the vast majority of the childbirths in India occurred at home. Figure 2.8: Place of delivery. Source: WHO, 2012f As earlier discussed, reduces the presence of a Skilled Birth Attendant (SBA 1 ) the risk of a woman dying during or after childbirth substantially. In the years 2005/2006 approximately 47% of births in India were assisted by SBA. Women that delivered their children in urban areas were more often assisted by a SBA. Figure 2.9 shows the degree in which SBA s were present during childbirth. 1. In India a skilled provider includes a doctor, auxiliary nurse midwife, nurse, midwife, lady health visitor and other health personnel. 38

39 Figure 2.9: Births assisted by a SBA in India. Source: WHO, 2012f When looking at the socioeconomic status of women it can be noticed that the poorest women had almost 5 times less access to skilled care compared to those that are part of the richest wealth quintiles. Figure 2.10 shows the births that have been assisted by a SBA, subdivided by socioeconomic status. Figure 2.10: Births assisted by a SBA by wealth quintile. Source: WHO, 2012f 2.5 Regional Context In this paragraph information will be given about the state Uttar Pradesh and Lucknow, the city in which the present study has taken place. Firstly, the geographical location and demographic information of Uttar Pradesh will be presented. Next, the maternal health status of the state will be discussed. Subsequently, these factors will be discussed for the capital city Lucknow. The foci of these sections will be laid upon urban maternal health as the present study takes place in an urban setting Geographical location and demographics Uttar Pradesh (U.P.) is located in north western India, bordering Nepal and the Indian states Uttarakhand and Delhi to the north. It shares its national borders also to Bihar to the east, Jharkhand to the southeast, Chhattisgarh to the south, Madhya Pradesh to the southwest and Rajasthan to the west. U.P. is the most populous state in India, with a population of 199,581,477 million people (Census, 2011). Figure 2.11 displays the geographical location of U.P. 39

40 Figure 2.11: Uttar Pradesh district map. Source: New Kerala, 2012 The State consists out of 70 districts in which 69 cities and towns are located. The total urban population of persons makes up for 12.7% of the total Indian population (Gov. of India 2010). The total slum population has 4,395,276 citizens. On average, households in U.P. consist out of six members of which 14% are headed by women (NFHS-3, 2006). Household heads are predominantly Hindu (82%) or Muslim (17%). Many of the people living in U.P. belong to marginalized groups as 25% of the residents belong to the scheduled castes, 1% belongs to the scheduled tribes and 50% belongs to other backward classes. U.P s population can be considered as a young population as a high proportion is underage. 42% of the population is younger than 15 years and only 5% is older than 65 years. The median age at first marriage in U.P. is 16.2 years for women and 20.1 years for men. Of the married women, 59% got married before the legal minimum age of 18 compared to 51% of the men. The fertility rate in U.P. is the second highest of India. The average amount of children that women in India have during their lifetime is less than 3 children, in U.P. women have about four children in this time span. U.P. is one of the least developed states in India in terms of socio-economic and demographic terms (Singh et al, 1998). In this state 29% of the households live in a permanent house that is called a Pucca. The following housing characteristics can be distinguished amongst all households: 43% of the households have electricity, 67% have no toilet facilities, 94% has a improved source of drinking water but only 9% has a water facility at home. Although India s national poverty s ratios have rapidly reduced, the ratios in U.P. have only shown a 40

41 marginal decline. On average 25% of the population of U.P. belongs in the lowest quintile of the wealth index and 14% of the population belong to the highest quintile (NFHS-3, 2006). These disparities are higher in rural areas as 36% of the rural households are in the lowest wealth quintile. In urban areas 4% of the households are in the lowest wealth quintile. In U.P. a strong preference for sons can be noticed as 34% of women and 28% of the men have indicated that they would like to have more sons than daughters. The gender disparity can also be noticed in U.P s enrollment ratios as 64% of girls between 6-17 years are attending school while 74% of the boys in this age group are enrolled (NFHS-3, 2006) Maternal health in Uttar Pradesh Uttar Pradesh is one of the states with the highest MMR with up to 517 deaths per 100,000 live births in Low uptake of ante-natal health care services and delivery services characterize maternal health in UP (Richard et. al. 2002, Singh et al, 1998). The NFHS-3 shows that on average 23% the women that gave birth between , received ANC from a doctor and 43% from other health personnel for their last birth. The remaining 34% did not receive any ANC. The utilization of ANC is higher in urban areas where 79% received ANC. In rural areas 62% of the women used this care. Despite these promising numbers the amount of ANC visits is insufficient as only 27% of the pregnant women in U.P. utilized the recommended minimum of 3 ANC visits. When comparing these numbers U.P. has the second lowest ANC utilization visits of all states and falls far behind on the national average of 52%. Younger, urban Hindu women with more education that have their first child are found to be more likely to receive ANC. Scheduled tribe women and those that are Muslim are less likely to receive this care. About 90% of the women that belong to the highest wealth quintile utilize ANC, only about half of the lowest quintile does this as well. In U.P, 78% of the women give birth at home in comparison to the national average of 65%. Only 22% of the births take place in a health facility, the national average is 39%. The lack of a SBA during childbirth is also more prevalent in U.P. in comparison to other states in India. Of the births that took place in % were assisted by a health professional and 40% of the baby s were delivered by a traditional birth attendant. The remaining 33% of the deliveries took place with the assistance of a relative or untrained person. The intra-country disparity and low rank of U.P. with respect to access to skilled care is demonstrated by figure Figure 2.12: Childbirth under guidance of a SBA. Source: WHO, 2012f 41

42 The utilization of postnatal care is extremely low as on average only 15% of the mothers had a postnatal check-up after giving birth. The recommended checkup within two days after giving birth was only 13%. Of the PNC that was received, 44% took place after women gave birth in a medical facility. Only 3% of the home births were followed by a checkup. Factors that are interlinked with poverty and ineffective or unaffordable health services are seen as the key causes for the high MMR in Urban U.P. The lack of political, managerial and administrative will is also often seen as an underlying cause for these high maternal mortality rates. The Indian health care system for Urban areas differs for each State; a commonality is that they are often unable to manage primary health care for its citizens. The urban public health care often deal with numeral problems such as shortage of funding, shortage of human resources, limited public private partnerships, dysfunctional referral systems, underutilized primary health care centers and an over load on tertiary hospitals (Govt. of India, 2010). Urban poor in India often visit private health facilities to meet their needs as government facilities are often seen as inadequate of doing so. The private sector in urban areas often consist out of private practitioners and small nursing homes with 1-20 beds that serve curative care for mostly urban and semi-urban clients Lucknow city, geographical location and demographics In the following paragraph information will be given about the capital city of U.P. Lucknow where the present study has taken place. Lucknow became a million-plus city in 1981 (LCDP, 2006). Last year Lucknow had residents, ranking it as the 11th biggest city in India (Census, 2011). The population grew extensively as the jurisdiction of the Lucknow Municipal Corporation was extended. Despite the decrease in population density during these years there can be noticed an upwards trend as the population density has grown due to population growth. The city is therefore rapidly expanding in the urban areas at the banks of the Gomti river. The population has also grown under the influence of rural to urban and urban to urban migration as the city attracts many migrants that are looking for better employment opportunities. Often these new migrants can be found in these informal settlements. Alongside the rapid growth of the city, Lucknow has also witnessed a growth in slum areas. According to the Improvement and Clearance Act of 1962 an area is a slum if the majority of buildings in the area are dilapidated, are over-crowded, have faulty arrangement of buildings or streets, narrow streets, lack ventilation, light or sanitation facilities, and are detrimental to safety, health or morals of the inhabitants in that area, or otherwise in any respect unfit for human habitation. Factors such as repairs, stability, extent of dampness, availability of natural light and air, water supply; arrangement of drainage and sanitation facilities are also taken into account (LCDP, 2006, p. ) It is estimated that 60 to 70% of Lucknow s population lives below the poverty line. The slum areas are scattered around the city but are often found in the river bed of the Gomti river, at both sides of the Hyder canal, in the vicinity of the railway tracks and alongside the Lucknow-Faizabad road. It is estimated that there are slum areas present in Lucknow. In Lucknow there are authorized and unauthorized slums. In the first type 85% of the houses are Pucca houses, in the latter this is only 40%. Figure 2.13 shows the map of Lucknow city 42

43 Figure 2.13: Map Lucknow city. Source: Google Maps, 2012 There are 393,000 households located in Lucknow city. The majority of Lucknow's population consists out of people from eastern U.P. However, also people from other regions can be distinguished as also Bengalis, South Indians and Anglo-Indians have settled in Lucknow (UHI, 2010). The vast majority of Lucknow s residents are Hindu (77%) or Muslim (20%). Other religions that are present are small groups of Sikhs, Jains, Christians and Buddhists. The sex ratio in this city is 915 females per 1000 males, corresponding closely with the national average of 914 females for 1000 males. The disparities are bigger in the sex ratio for children as there are 901 girls per 1000 boys. However, Lucknow has shown a positive trend with respect to gender disparity as in 1971 the ratio was 829 females for 1000 males (LCDP, 2006). Yet, the cause of this development can be debated as the growth of the percentage of women can also be attributed by the mobility of male family members. Many men work outside the city and leave their female family members behind in the city as it is seen as a good environment The health care system in Lucknow city The public health care in Lucknow is greatly underfunded as health is one of the cities lowest expenditures. Less than 1% has been spent on health for the last five years. The health services in this city are provided by the public sector and private sector. The prevalent emergence of the private sector in India, can also be witnessed in Lucknow. The private sector in health consists out of private hospitals, nursing homes and clinics. These private facilities play a major role in the provision of general and maternal health services to the urban poor. In addition charitable hospitals can be recognized which provide subsidized health services to the poor. The public health facilities consist out of public hospitals, Railways hospitals, dispensaries and Cantonment hospitals and dispensaries. The public health structure is mainly operated by the Department of Medical Health and Family Welfare and The Lucknow Municipal Corporation. In the this health care system two different levels can be witnessed namely, First Tier facilities and Second tier facilities. Via the First Tier facilities primary health care is provided in various parts of the city. Facilities that fall under this section are for instance Urban Family Welfare Centers, School Health Dispensaries and Medical Care Units. The provision of ANC registration and ANC checkups are one of their 43

44 main jobs. The Second Tier facilities consist out of male and female or joint hospitals. These facilities provide secondary health care the community s located in Lucknow. In Lucknow there are one government medical university and seven other secondary care health facilities are available. Apart from these facilities there are nine Bal Mahila Chikitsalya s available. These mother and child centers are appointed to provide maternal health services to women that are part of vulnerable groups. These centers provide basic ANC, delivery care and PNC. However, for many services such as ultrasounds or assistance during life threatening births, women have to be referred to hospitals. The distribution of maternal health services in communities falls under the Integrated Child Development Services structure. The Lucknow director of this program directs Child Development Programme Officer (CDPO) that focuses on maternal and child health subjects. Anganwadi workers, that fall under the CDPO, are active on the community level. Each Anganwadi Center (AWC) serves 1000 people. The Accredited Social Health Activists (ASHAs) also work in the community as their goal is to create awareness on health and its social determinants amongst women and communities and to increase the utilization of health and the accountability of the health services. Although ASHA s originally were trained to work in rural areas they also work with urban communities. In Lucknow many of the health care challenges that India faces can be recognized. The overcrowding of patients can be witnessed as many first tier health facilities have to provide care for a to population (UHI, 2010). The centers are set to deliver care to a population of This overload can also be witnessed amongst Auxiliary Nurse Midwives (ANM s) that are also in charge of delivering health care in slum areas and convincing women to have an institutional birth. They often have to cater to 500 persons instead of a 100. The affordability of health services is also a major challenge for the urban poor. The monthly household income in rupees in Urban slums varies from rupees (10.38%), (31.11%), (36.63%), (14.90%) and above 4000 (5.79%). On average 30% of the household income in Lucknow is spent on health, resulting in many families taking a loan to be able to cover their health expenditures. In Lucknow 47.3% of the births that take place are institutional births, it is expected that many women make part of a higher wealth quintile. Information about the accessibility and utilization of maternal health care services in Lucknow is unfortunately not available as disagreements about the definition of slums and about data have prevented scholars to draw conclusions about service delivery challenges in slum areas (LCDP, 2006). 2.6 Conclusion This chapter has shown that India is a diverse country with respect to its geography, population and culture. Although many positive trends can be noticed in the highly populated country s development, major challenges in the field of poverty reduction and maternal heath continue to exist. The perseverant cast system and prevailing gender inequalities on top of supply and demand side barriers prevent women from accessing maternal health care in its fullest form. As the utilization rates of antenatal care, delivery care and postnatal care show positive signs during the last years, many challenges lie ahead as many women from low socio-economic groups do not attribute to this trend. As the diverse country of India shows different development stories with respect to maternal health it is of key importance that information is gathered about the maternal health care use by the poor and its accessibility throughout the country. In order to decrease the information gap in the capital city Lucknow, this modest present study aims to contribute to the data collection. In the following chapter information will be given about the way the present research has been conducted. 44

45 Chapter 3 Methodology 3.1 Introduction In this chapter the research questions and conceptual model of the present research will be discussed. Next, information will be given about the chosen research methods such as the type of research, data collection methods and the target group. Also, the main limitations and risks of the study will be addressed in this chapter. 3.2 Research questions In the following paragraph the research questions and the conceptual model of this study will be presented Research questions In order to get a better understanding of the maternal health care use in medical facilities in urban Lucknow, the barriers that women come across when wanting the utilize this type of care and the influence that utilization has on their possible future behavior the following research question was designed: What experiences do women of low socio-economic status have, living in Kashyap Nagar Lucknow, with respect to accessing and utilizing public and private maternal health care services, and how can this be expected to influence their future health seeking behavior? The research took place in the urban slum Kashyap Nagar. More information about the selection and location of this community will be given in paragraph 3.4. In order to research the above mentioned facets the following sub-questions have been formulated: To what extent do women from Kashyap Nagar utilize public and private maternal health care services? What motivates women to utilize maternal health care? How do these women select the location where the maternal health care will be utilized? Which barriers reduce the accessibility of maternal health care services for these women, and how do the women in question overcome these? What kind of experiences do women from Kashyap Nagar have with utilizing public and private maternal health care medical facilities? What factors do women expect to influence their future health seeking behavior? Conceptual model Based on the information presented in the theoretical framework, some assumptions of the factors that influence the accessibility and utilization of maternal health care services can be made. Based on the literature overview it can be assumed that when the need for maternal health care is recognized, by the woman, her family or community, health care might be sought. Although health seeking behavior on its own is a complex and interesting research topic, it will not be fully included in this research. The present study lays it foci on the process that women experience once the choice to utilize maternal health care (MHC) is made. The accessibility of 45

46 these services is influenced by several demand and supply side barriers. The possible demand side barriers can be brought down to three overarching dimensions: physical factors such as the living distance and travel time from a health care facility, socioeconomic variables such as the ability to pay for services and the cultural acceptability of maternal health care and the personal variables of the women such as education level and household composition. These factors can either function as a barrier preventing women from utilizing MHC or have a minimal or no negative influence on the accessibility of a service. However, during the accessing phase it is also possible that a woman comes across supply side barriers that make it not possible to utilize the services. Supply side barriers that hamper the accessibility can for instance be the facilities opening hours that do not correspond with the women s needs or health personnel asking for bribes. If women do utilize MHC they can come across other supply side factors that have a negative influence on their utilization experience. Such barriers can for instance be the health personnel of a facility that treat women disrespectfully or inadequate care that is being received by the women. These experiences can have negative influencing on the continuation of the maternal health care, as women subsequently could decide to not utilize al ANC services or not to deliver their child in a facility. The dissatisfaction of the patients with regard to the utilized services can also have a negative influence on anticipated future use of MHC for the women themselves and their family and community members as their stories might convince other women to not utilize any MHC as well. These connections and assumptions are translated into a conceptual model that is displayed in figure 3.1. The boxes that are marked in blue showcase the focus of the present study. 46

47 Figure 3.1 Conceptual Model Accessibility and Utilization Reproductive Health Care Policies, Institutions, Organizations and processes No Access Physical Factors Need for Maternal health care Recognized Access Quality MHC Utilization Socioeconomic Factors Personal variables Women Health Seeking Behavior Patient Satisfaction Unacceptable Acceptable Decrease in level of future utilization

48 3.3. Research methods The following paragraph will give information about the chosen research approach and the methods that have been used to collect data. In addition, the host organization that guided this research and that will be using the research findings will be introduced Research approach and methods For this research a mixed method approach has been used that combines quantitative and qualitative methods. This approach has been selected as it brings potential benefits in terms of data quality and depth of understanding (Hulme, 2007). By gathering quantitative data a large overview can be given of the MHC use and the barriers that women have come across when accessing these services. The qualitative information will be used to get a better idea of the context and how the quantitative can be interpreted. The study researches the topic from the rights holders perspective, and aims to contribute to the accountability of the duty bearers in Lucknow. For this study data has been collected via the main research method a questionnaire and via the use of interviews. In order to gather information from the women s perspective a questionnaire has been developed that has been used to survey 50 women that live in the slum Kashyap Nagar. Additional interview questions have been asked about the context of their story. The information derived from the interviews has been used to compile case studies that represent the diverse stories that were told by various women. Selection of the women took place while the women were surveyed. The selection criteria were based upon the earlier provided information by the participant, the level of representativeness of the stories and the insights that could be given by these stories. Also the level of trust that developed between researcher and recherché was taken into account. In order to get insight in the perspective of the supply side, addition interview questions for this research have been formulated by the researcher and included in the interviews scheme used by fellow International Development Studies student Prarthana Ramdas. These questions were asked Ms. Ramdas during the interviews with doctors of the by her researched public and private facilities. By integrating these questions it was possible to gather information about the perspective of health workers on certain topics that the women were also asked about for this study. The questions focused on the perspectives that doctors had on the MHC utilization behavior of women, the communication with women from low socioeconomic groups, additional costs for drug prescriptions and the expectations of women with respect to the MHC services The questionnaire The questionnaire has been used to gather data about the knowledge, attitudes and behaviors of the target group of this study. The theoretical approaches to the accessibility of health services have been integrated in this questionnaire by the formulation of questions that address the five accessibility dimensions (availability, accessibility, affordability, adequacy and acceptability). Also, gender related questions have been incorporated in this questionnaire in order to get a basic understanding of the women s autonomy. The questionnaire consists out of 164 questions, which have lead to 200 variables that could be analyzed. The questionnaire consists for a large part out of closed questions meaning, that questions with a set of fixed alternatives were presented to the women from which they could choose an appropriate answer. The use of closed end questions was based on the advantage that they offer as the data derived from these type of questions is easier to process and has a higher level of comparability, especially when working with translators (Desai & Potter, 2006). In

49 addition, several open answer questions have been included in the questionnaire as it brings variation within the questionnaire and present women with the option to answer spontaneous. The questionnaire consists out of five sections, each focusing on different aspects of the research question. Within the questionnaire different routes can be taken, based upon the answers that have been given. This way information can be gathered about the reasoning why women did or did not make certain choices. The first section of the questionnaire aims to gather information about the health seeking behavior of the woman and the care that she has received. It aims to find out which ANC she utilized and how often and what the reasoning behind this decision was. Also questions with regard to the selection of the location where the care was received, the health personnel she had contact with and role of her surroundings in selecting the health facility are included in this section. The second section focuses on the experiences women had while utilizing MHC. Different questions are being asked to get an understanding of the way the supply side met the expectations of the women. Special attention is being paid to the dimensions adequacy and acceptability. Questions are being asked with regard to the communication with health personnel, referral and the use of private facilities. The third section addresses the barriers that women can come across when wanting to utilize MHC. Both supply and demand side barriers have been incorporated in this section. Additional open ended questions have been asked to get a perspective on to how women have dealt with these barriers and if they have use conditional cash transfer schemes during their last pregnancy. In the fourth section attention is paid to the anticipated future use of MHC by the women in order to determine the influence of prior experiences with accessing and utilizing MHC. In the last section background questions are asked such as the household composition, income and educational background. The full questionnaire can be found in Appendix A of this thesis report Operationalization of concepts Within this study different concepts have been used. Although many are self explanatory or imbedded in the theoretical framework a few key concepts will be exemplified in this paragraph. Utilization; the level of use (Joseph & Phillips, 1984). In the context of this research; the use of maternal health care services. The level of utilization will be measured by the use of several questions in the survey that will address the previous use of maternal health care services by women of whom the target group exists. This will be measured by the use of personal factual closed questions. If women indicate that they have indicated MHC, questions were asked about the degree of use to find out which maternal health care services were utilized. Negative physical factors; physical factors that can act as barriers when one wants to utilize the maternal health care services. These physical factors can encompass barriers such as a long distance to a health facility and no financial means to travel the distance to the facility. This variable has been measured by the use of questions that address the attitude of the respondent with respect to the degree this variable is seen as a barrier. This attitude has been measured by the use of statements that can be interpreted by either the positive or negative response that has been given by the respondent. The following measurements have been used; strongly disagree, disagree, neither agree nor disagree, agree and strongly agree. Satisfaction level; the fulfillment of a need. In the context of this research; the fulfillment of the needs that women have with respect to the care and treatment they expect to receive when 49

50 utilizing the services in public or private facilities. This variable has been measured by the use of questions that address the attitude of the respondent with respect to the degree their expectations have been met by the facilities. This attitude has also been measured by the use of a likert scale. Expecting; to feel or realize beforehand. In the context of this research; the expectations of future utilization behavior that women have based on their previous experiences with respect to accessing and utilizing maternal health services. This variable has been measured by the questions that address the weight that is given to past experiences and the influence this has on the attitudes that women have towards maternal health care or the facilities that offer these services The host organization When conducting research in a foreign country it of key importance that local knowledge of the region and context is taken into account. Therefore, this research has been conducted in cooperation with a local Non Government Organization (NGO) called SAHAYOG. SAHAYOG is an Indian NGO founded in 1992 and is based in Lucknow, Uttar Pradesh. The organization has the following mission: promote gender equality and women s health from a human rights framework by strengthening partnership-based advocacy (SAHAYOG, 2011). Values that play an important role in the way this organization operates are equity and equality, participation, transparency and effectiveness. The strategic issues that the organization has focused on in the past include the themes Maternal Health and Rights, Gender Equality, Masculinities and ending Violence against Women and Youth Sexual and Reproductive Rights and Health. The following four strategies are being used within the organization: Facilitating and building capacities of community-based organizations Anchoring civil society networks for campaigns and advocacy Capacity building for research and monitoring Information production and dissemination The theme Maternal Health is translated to an approach that promotes women's right to maternal health. Focus is placed on access, accountability and entitlements. SAHAYOG s interventions to improve maternal health adopt rights-based approaches that put women at the centre and enhance their agency in claiming their right to health (SAHAYOG, 2011). Attention is given to different levels ranging from community to policy level. The present study has been adapted to the wishes and interests of SAHAYOG s so that the research results can be of use in practice Selection of the research area and units In the following paragraph information will be given about the selection of the research are and the research participants. Next, information will be given about the context in which the research took place and the main limitations and risks of this research Selection of the research area The selection of the research area for this present study has been based on local knowledge. This decision was made as it is very challenging to targeting people who are considered poor as income data India can be unreliable and not all slums in Lucknow are registered (Govt. of India, 50

51 2010). Spatial targeting is also complicated as the issuing of Below Poverty Line (BPL) cards is often not up to date, and not well-documented. Additionally, migration leads to the scattering of living spaces in urban areas, which means that the target group for this study could not exactly be mapped out by using geographical location as a guide. This is also the case in Lucknow City where the large numbers of poor live scattered throughout the city (UHI, 2010). Therefore, it is recommended that individuals who are familiar with the area, are being used to identify the locations where the poor can be found (Govt. of India, 2010). As SAHAYOG does not work in urban areas, the host organization had limited knowledge about suitable research sites. Therefore, Mrs. Sudha Singh who works for the local NGO Humsafar was contacted to help locate a suitable research area where the target group could be found. As she works in several slums in Lucknow she comes across many women that have a low socioeconomic status and that would fit the description of the target group. Therefore, she was appointed by SAHAYOG as the most suitable person to select possible research areas. Under her supervision the following urban areas were selected: Janta Nagra, Baad Shahbagh, Qutuppur and Kashyap Nagar. It was decided that Kashyap Nagar would be the most suitable location for the data collection as Mrs. Singh herself lives in Kashyap Nagar. Because of her formal and informal relationships with these women and the surrounding community she has a strongly established a trust level with them. This was an important factor for selecting Kashyap Nagar as the research location it is often seen as very difficult to establish trust levels of such manner with women that live in a slum based community. Hence, influencing their willingness to participate in the research. In addition, Mrs. Singh knew it was possible to find 50 women within this one community that would match the target population description, making the fieldwork less expensive and less time consuming. Kashyap Nagar can be seen as a representative slum area as there are many communities in Lucknow that share commonalities with this community such as the type of housing, poverty levels and household compositions. However, there are communities in Lucknow that are with their migrant resident seen as more vulnerable. As neither HUMSAFAR, nor any of the other partner organizations of SAHAYOG had any contacts with these communities, it was not possible to conduct fieldwork in these areas in the limited time that was available for this research Description and selection of the research units The women or research units in this study had to meet certain requirements in order to be found eligible to participate. Firstly it was important that they were part of a low socioeconomic group. The selection was based on their residency in a slum area. The Wealth Index was used as a control method. It was considered to use the household income or caste of the women to define their socioeconomic position. However, both were seen as ineffective by the host organization and reports (Govt. of India, 2010). As policies against caste-based discrimination have gained ground, the membership of a scheduled tribe or caste no longer inevitably correlates with socioeconomic disadvantaged position within society (Moore et. al, 2006). Assessing ones socioeconomic status by the use of income standards is often seen as questionable and misleading as information is often incorrect. By using a Wealth Index, a ranking system that was used for the National Family Health Survey in Uttar Pradesh, a control mechanism was implemented to get a better understanding of the means that the women and their families have. During the fieldwork data was collected that made it possible to calculate their rank in the Wealth Index. This system combines information on 33 household assets and housing characteristics that all have an equal weight when calculating the wealth of a household. The total score in this index is afterwards 51

52 translated to a rank in one of the five wealth quintiles (IIPS, 2008). The original Wealth Index was partially transformed to make it more suitable for use in urban areas. Although the Wealth Index weights al factors equally and therefore cannot be seen as a waterproof method it is helpful in categorizing households other than by only looking at their income or caste (see Appendix B for the Wealth Index and the score results of the researched households). Secondly, the age of the women was taken into account. It was decided that in order for women to be found eligible for this research they had to be between the ages of This age range was based on marital and childbirth information. The approximate childbearing years in India starts at age 18 and ends at age 50 (Moore et. al, 2009). Research shows that the average age of Indian women at marriage is 18.2 years old and that in Uttar Pradesh women are 17.5 years old (Unicef, 2007). However, in UP, 59% of women of age get married before the legal minimum age of 18 (IIPS, 2008). Yet, this information could not be representative for the research area as studies have also shown that the mean age of women who are married and living in Indian urban slums is 13.8 years old (Govt. of India, 2010). The mean age at which the marriage is consummated by these girls is 16 years old. On average, women become mothers after about two years after marriage (Moore et. al, 2009) and about 14% of women living in urban UP between the age of have begun their childbearing period (IIPS, 2008). Therefore, girls of 15 years old will also be included in the research. Lastly, the household composition of women was taken into account. As the research focuses on the experiences that women have had while accessing and utilizing maternal health care services, women had a minimum of 1 live or still born birth in the last 3 to 24 months were targeted. By only including women who gave birth in the 3 to 24 months prior to the research, women would be able to recall their experiences more clearly hence, increasing the accuracy of this research. In addition their experiences would be more representative with respect to the current health system and facilities within in Lucknow. It was decided not to involve women that were pregnant or gave birth in the last two months prior to the research as they might not utilized all the services that MHC encompasses. All research conducted was based on the experiences that women had with respect to their youngest child. This way, information would be most up to date and more accurate as it could be prevented that women would tell stories based on their experiences from other pregnancies as well. When selecting the research units no distinction was made with respect to their religion and marital grounds as these factors are not seen as factors that should be controlled for. The researched women were selected by Mrs. Singh based upon the above mentioned requirements. As she had knowledge about which women gave birth in the last three to twelve months she could approach these women directly. When asking them to participate in the research the women often had to have the consent from either their husband or mother in-law before participating. When giving information about the research and the survey that would be used, all approached women and their family gave their consent to participate in the research. Leading to a non-response of 0%. Appointments with the women were made so that it was possible to take questionnaires and interview the women in a short time span. many women could be surveyed. The women either visited Mrs. Singh s house to be surveyed or were visited by the research team, depending on their own wishes or those of their family. It was stimulated to visit Mrs. Singh s house as it would be more time efficient and the women would feel less hampered in answering questions truthfully as no family members would watching over their shoulder. 52

53 Research team The research was carried out by 3 research assistants and myself. Two teams were formed, consisting out of Ms. Singh working together with Ms. Ramdas and Ms. Sneha Gupta who was working together with me. All research assistants were trained before starting the fieldwork. Attention was paid to diverse topics such as the research questions, survey questions, ethics, financial compensation and working schedules. All the assistants received a guidebook in which the some of this important information was mentioned again (please see Appendix C for the guidebook). The fieldwork took place in week 13 and the data was collected by the research team in 5 days. The team worked in the slum Kashyap Nagar and interviewed the women at the home of Mrs. Singh and at the homes of the researched women. The research materials were designed in English and later on translated by Shraddha Pandey and Shishir Chandra of SAHAYOG. The order of the answering options in the Hindi and English version were compared by Miss. Gupta so that the data entered in SPSS would be correct Ethics When conducting fieldwork, especially in developing countries or those in transition, ethical dynamics relating to knowledge generation, ownership and exploitation have to be taken into account. Different kinds of barriers can develop based on the power differences between researcher and researched, hidden assumptions and the behavior of the researcher. In order to safeguard the position and power of the researched women an information sheet and consent form were designed, based on the documents used by Ms. Rachel Bell 2. In these forms, information is given about the research and the rights that the women have (see Appendix D for the information sheet and Appendix E for the consent form). The research assistants had been trained to give the women all the information they wanted and to let them sign the consent form in which they state that they understand their rights. When the women were not able to write themselves they signed with their fingerprint Main limitations and risks With every research there are limitations and risks that have to be taken into account. In this case, the main limitations were related to the available time and funds. During the first weeks of the internship it became clear that SAHAYOG did not have a specific research question and was not able to assist in finding or selecting possible urban research locations or to provide a budget or assistance for the fieldwork. As a result, a lot of time had to be spend on finding a good research perspective and researching the city. Luckily, SAHAYOG was able to introduce Mrs. Sudha Singh of the NGO HUMSAFAR that had the knowledge that was necessary. However, as she had obligations to her own organization it was in the beginning very difficult for her to find the time to assist me in my research. Multiple appointments were postponed or cancelled, making it impossible to visit different research sites or to conduct a try-out. Another reason causing delays was the process of finding suitable translators/research assistants for the data collection and the translation of research materials. The fieldwork also had to be postponed as the research materials were not translated on time or were not translated correctly and because of the unforeseen cancellation of a research assistant. Because of the above mentioned limitations the 2 Rachel Bell has conducted a baseline study on Maternal Health Practices and Services in Relation to the IGMSY Conditional Maternity Benefit for her International Development Studies master thesis in the school year 2010/2011 in cooperation with SAGAYOG. 53

54 fieldwork was postponed to the last month of the 3 month internship and had to be finished in 5 days, making it not possible to adjust research methods to the situation in the field. Another limitation was the small budget on which the research had to be conducted. Understandably, SAHAYOG did not have budget to support the research. As a result the data collection targets and methods, as designed in the research proposal, had to be altered. As there were fixed prices for the compensation of research assistants, and volunteers were not able to assist, it would have become too expensive to carry out the original research plan myself. As a result the target group was brought back to 50 women and the research costs were reduced to INR As a result of decreasing the target group, the researched women cannot be seen as a representative sample of the proposed population. Also, it was not possible to use the earlier developed probability sampling strategy to retrieve a representative sample of the target group. As it was not possible to meet the Child Development Programme Officer or the Anganwadi worker of the locale centre, it was also not possible to gather information about the population of which the target group is part of. The limitations also reflected on the earlier proposed research methods. The focus group meetings and additional interviews could not be carried out as there was no time and no funds available for these extra methods. The risks involved in this study are mainly interlinked with the language barrier. My inability to speak Hindi made it only possible to guide the conducted fieldwork in an indirect manner. As I could not personally check the translated research materials or possible wrong interpretations during the fieldwork, it was very difficult to get an understanding of possible mistakes or different ways in which the survey was carried out. Although the survey mainly consists out of closed ended questions, it is inevitable that differences in interpretations of filling in answers have taken place. By reading along the survey questions in my English version, asking control questions and talking about the surveying with the translators it was tried to minimize these risks Conclusion In order to get a better understanding of the maternal health care use in Urban Lucknow, the barriers that women come across when wanting the utilize this type of care and the influence that utilization has on their possible future behavior research was conducted in Kashyap Nagar. Data was gathered through the use of a questionnaire and via interviews. Although the present study encountered various limitations it was possible to gather data of 50 women. In the following chapter information will be given about who these women are and their living conditions in the slum Kashyap Nagar. Subsequently, will the gathered research data be presented in the chapter five. 54

55 Chapter 4 Research location and participants 4.1. Introduction This chapter aims to provide an understanding of the background in which the research has taken place. In the first paragraph information will be given of the research area, the slum Kashyap Nagar. In the second paragraph the personal variables of the researched women and their maternal history will be discussed. 4.2 Research location The data collection for the research has taken place in Kashyap Nagar, a community that is part of the urban city block Daliganj in Lucknow. Daliganj is located in the old part of the city centre that once was established in the Nawab period (LCDP, 2006). Currently, this settlement and those alike are known for being densely populated and having inadequate infrastructure. Within Daliganj residents different socioeconomic groups can be distinguished, ranging from wealthy families to the poorest of Lucknow. Kashyap Nagar is located north of the Gomti river, and inhabits approximately 600 families. This community is divided in two parts, Kashyap Nagar 1 where about families live, and Kashyap Nagar 2, that houses approximately 200 families. The latter is also seen as the periphery of Kashyap Nagar. The families that are currently living in Kashyap Nagar are of the second and third generation of the original residents to this area over 50 years ago. Kashyap Nagar has been classified as a slum in 2006 by the development council of Lucknow. This classification is based on the absence of a paved road, the absence of safe sanitation, the absence of primary health care facilities and its resident s unsafe tenure. The degree of tenure in the community differs between the families. The families living in the center of the community possess permits that have been allocated by the government, giving these residents permission to use the government land for housing up to 90 years. After that the government decides whether or not the permit will be extended for another 90 years. Because of this regulation, a big proportion of Kashyap Nagar s population has some sort of safe tenure. Yet, this does not apply to all residents. As there are also families that have not received this permit, a proportion of Kashyap Nagar s residents are living illegally on government land, subsequently leading to unsafe tenure. The residents of Kashyap Nagar have used diverse building materials for the houses. The most common materials that have been are semen, bricks, mud, metal roofs, plastics and PCV. Often bricks and tires are being used to attach the roof to the rest of the house. Some houses have water facilities or toilets inside. Often, water tanks are being used by these residents. Also, some pipelines have been installed in the community. However, the water coming out of it is according to the community very unhygienic and has a bad smell. The residents that lack sanitation means use the river and river bank for washing and toilet purposes. Women are constraint by this as they can only go to the riverbank for toilet use in the dark. 55

56 Figure 4.1. Satellite picture of Lucknow city. Source Google Maps Source Google maps Figure 4.2. Satellite picture of Kashyap Nagar Source Google Maps Source Google maps 4.3 Research units This paragraph will give an overview of the household situation of the researched women and their previous pregnancies Household situation The research units for this research consist out of 50 women with a low socioeconomic status, living in the urban slum Kashyap Nagar. The women that participated in the research were between ages of 19 and 35 years old and have a mean age of 24 years old. Of these women 40% live in a joint family and 56% live in a nuclear family. One woman indicated that she lives alone. On one woman no data was available. All women indicated that they were married. The approximate monthly household income is INR The income range has a minimum of a monthly income of INR.1000 and a maximum of INR In most of the households the men were the main providers, working full time and outside the home, often as a day laborer (42%). Other income generating jobs of the husbands consist out of selling fruit or fish or other products as a street vendor, working in a factory or private shop, driving tempo s, farming, or working as a servant, painter, rickshaw puller or electric house worker. Often these jobs are on project base, meaning that many families don t have a steady income. Six of the women indicated that they had income generating jobs as three women did stitching work, two women washed dishes and one woman performed household work for another family. 54% of the women indicated that they had a say in how the household money is being spend, 58% also indicated that they could spend family money without consulting their family members first. This often applies to the full household income according to the researched women. The average Wealth Index rank of the women was rank 2 (52%), indicating that the women are part of a low socioeconomic group. 28% of the women is categorized as rank 1, meaning that they are part of the lowest socioeconomic group. The remaining 20% has been categorized as belonging to rank 3, meaning that they are somewhat better off. None of the researched women had a rank higher than rank 3. Most of the women indicated that they are part of the caste group Kashyap (52%) that is seen as an OBC. The remaining women were part 56